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THE    SUEGEPtY 

OF 

THE    ALIMENTARY    CANAL 


A   TREATISE  ON 


THE    SUEGEKY 

OF 

THE   ALIMENTARY   CANAL 


COMPEISING 


THE   (ESOPHAGUS,  THE   STOMACH, 

THE     SMALL     AND    LAKGE     INTESTINES, 

AND    THE    KECTUM 


BY 

A.  EMEST  MAYLARD,  M.B.,  B.S.CLOND.) 

SURGEON'    TO    THE    VICTOEIA    INFIHMART,    GLASGOW 

EXAMINER    IN    SURGERY    TO    THE    CONJOINT    BOARD    OF    THE    ROYAL 

COLLKGKS    OP    PHYSICIANS   AND   SURGEONS    OP    EDINBURGH    AND    THE    FACULTY 

OP  PHYSICIANS  AND  SURGEON'S  OF  GLASGOW;     LATE    EXAMINER    IN    CLINICAL    SURGERY 

TO  THE    UNIVERSITY  OP  GLASGOW  ;    FORMERLY  EXTRA-HONORARY    SURGEON  TO 

THE  ROYAL   HOSPITAL  FOR  SICK  CHILDREN,  GLASGOW  ;   AND  DISPENSARY 

SURGEON    TO    THE    WESTERN    INFIRMARY,    GLASGOW  ;     LATB 

DEMONSTRATOR  OP  ANATOMY,  GUY'S  HOSPITAL,  LONDON 


LONDON 
J.    &    A.    CHUECHILL 

7  GREAT  MARLBOROUGH  STREET 
189G 


PEEFACE 


The  rapidly  growing  importance  of  the  treatment  by  surgery 
of  certain  diseases  of  the  oesophagus,  stomach,  and  intestines, 
and  the  great  adva,nces  which  have  been  made  along  this  par- 
ticular line  within  the  last  few  years,  are  sufficiently  well 
known  to  every  surgeon  not  to  require  any  general  introduc- 
tory remarks.  I  shall,  therefore,  limit  myself  to  a  brief 
statement  of  some  of  the  objects  I  had  in  view  in  endeavour- 
ing to  embrace  under  one  discussion,  subjects  which,  when 
treated  of  at  any  length,  are  usually  considered  separately, 
and  as  branches  of  surgery  to  be  practised  by  specialists 
rather  than  by  the  general  surgeon. 

The  almost  imperceptible  differences  which  exist  between 
the  symptoms  of  disease  in  one  part  of  the  alimentary  tract 
and  those  of  disease  in  another  and  distant  part,  make  it 
difficult  in  particular  cases  to  refer  them  to  their  proper 
source,  and  entail  upon  the  surgeon  for  diagnostic  purposes  a 
knowledge  of  all  the  regions  from  which  they  may  spring. 

The  same  argument  may  be  applied,  even  with  greater 
force,  to  the  subject  of  operative  treatment.  Thus,  how  often 
does  disease  in  the  oesophagus  necessitate  an  operation  upon 
the  stomach ;  and  disease  in  the  stomach  or  rectum  call  for 
an  operation  upon  the  intestines  ? 

The  ambiguity  which  at  present  exists  in  the  nomenclature 
of  operations  upon  the  various  sections  of  the  alimentary 
tract,  shows  how  great  is  the  need  of  some  kind  of  revision, 
based  upon  a  comprehensive  and  combined  consideration  of 

;7  4c5> 


VI      SURGEEY  OF  THE  ALIMENTARY  CANAL 

this  particular  section  of  the  subject.  We  find,  for  instance, 
similar  operations  in  different  parts  of  the  canal  described  by 
terms  which  are  etymologically  quite  different,  and,  vice  versa, 
terms  etymologically  alike  signifying  different  operations. 

Two  methods  of  dealing  with  the  subject  occurred  to  me. 
Either  I  might  take  certain  injuries  and  diseases,  and  deal 
with  them  as  they  respectively  affected  special  tracts  of  the 
canal ;  or  I  might  treat  the  subject  purely  regionally.  The 
former  method  offered  features  of  considerable  interest  from 
a  pathological  and  etiological  aspect ;  but  the  latter  seemed  to 
afford  a  better  scheme  for  purely  surgical  treatment.  The 
chief  difficulty,  however,  in  adopting  the  regional  method  lay 
in  drawing  the  line  between  certain  injuries  and  diseases 
affecting  such  regions,  for  instance,  as  the  jejunum  and 
ileum,  and  the  colon.  This  difficulty,  however,  has  been 
surmounted  by  attempting  no  such  division  in  certain  cases, 
but  combining  in  one  discussion  regions  where  the  injuries  or 
diseases  produce  practically  similar  symptoms. 

The  actual  portion  of  the  alimentary  tract  treated  extends 
from  the  commencement  of  the  oesophagus  to  the  termination 
of  the  rectum  proper — that  is  to  say,  the  anal  portion  of  the 
gut  is  not  included.  Hence  all  diseases  affecting  the  pharynx 
or  throat  are  excluded,  as  also  those  involving  the  anal 
portion  of  the  rectum.  This  latter  exclusion  involves,  there- 
fore, haemorrhoids,  fistula  in  ano,  anal  fissure,  and  anal  ulcer. 
Another  large  class  of  affection  is  excluded,  the  external 
hernise. 

In  order  to  depict  more  vividly  the  particular  injury  or 
disease  of  a  region,  I  have  supplemented  the  text  with  a  case. 
In  a  field  so  extensive,  it  was  not  possible  to  draw  exclusively 
from  my  own  resources  ;  hence  when  my  hospital  or  private 
case  books  failed  me,  I  strove  to  find  from  the  published 
records  such  as  seemed  best  to  serve  the  purpose  in  view.  I 
attached  much  importance  to  these  cases,  as  often  being  of 
more  interest  and  instruction  than  a  picture  illustration. 


PREFACE  vii 

With  regard  to  operations,  it  Beemed  that,  from  an  essen- 
tially practical  point  of  view,  it  would  be  better  to  include  all 
operations  upon  a  particular  region  in  one  or  more  chapters 
at  the  conclusion  of  the  discussion  of  the  injuries  and  diseases 
of  that  region.  By  so  doing,  there  would  need  to  be  no 
reduj)lication  of  description  when  one  particular  operation  is 
applicable  to  more  than  one  disease,  merely  a  reference  in 
the  text  to  the  operation  would  suffice.  The  only  exceptions 
to  this  division  are  in  the  case  of  special  operation  for  sjDecial 
cases,  as  for  instance  the  various  operations  in  vogue  for  the 
treatment  of  prolapse  of  the  rectum,  operations  which  bear 
the  name  of  a  particular,  surgeon  and  are  only  applicable  to 
particular  cases.  These,  and  others  like  them,  which  cannot 
be  exactly  termed  classical  operations,  are  introduced  in  the 
treatment  of  the  subject  to  which  they  specially  apply. 

Many  of  the  figures  introduced  to  illustrate  injuries  or 
diseases  have  been  taken  from  among  the  extensive  and  valu- 
able collection  of  specimens  contained  in  the  Pathological 
Museums  respectively  of  the  Western,  Eoyal,  and  Victoria 
Infirmaries,  and  from  the  Hunterian  of  the  University  of 
Glasgow.  For  permission  to  make  use  of  these  I  am  indebted 
to  Professor  Joseph  Coats,  Dr.  Charles  Workman,  Dr.  T.  K. 
Monro,  and  Professor  John  Young.  With  the  exception  of  the 
skiagraph  kindly  given  me  by  Dr.  John  MAcnsfTYRE,  all  the 
Plates  are  from  photographs  taken  by  my  Assistant  Colleague 
at  the  Victoria  Infirmary,  Dr.  J.  Grant  Andrew,  to  whom  I  am 
indebted  not  only  for  this  important  feature  in  the  work,  but 
for  the  arduous  labour  of  making  the  index. 

The  proofs  have  passed  through  the  careful  hands  of  Dr. 
Henry  Kutherfurd,  to  whom  I  am  also  under  an  obligation  for 
many  valuable  suggestions  in  the  course  of  the  work. 

I  cannot  conclude  without  acknowledging  the  assistance 
I  have  derived  from  the  valuable  work  upon  '  Diseases  of  the 
Throat  and  Nose  '  by  the  late  Sir  Morell  Mackenzie,  whose 
experience  in  affections  of  the  oesophagus  was  exceptionally 


Vni     SURGERY  OF  THE  ALIMENTARY  CANAL 

extensive.  To  Mr.  Frederick  Treves,  of  London,  I  must 
also  acknowledge  my  indebtedness.  His  work  and  numerous 
writings  have  done  much  to  advance  the  subject  of  gastro- 
intestinal surgery  in  this  country. 

Lastly,  I  wish  to  express  of  what  inestimable  service  the 
two  American  publications — the  *  Index  Medicus  '  and  the 
'  Annual  of  the  Universal  Medical  Sciences  ' — have  been  in 
enabling  me  to  accomplish  that  particular  and  important 
constituent  of  the  work  comprised  in  the  acquisition  of 
requisite  references. 

10  Blytikwood  Square,  G-la^jgow. 
October  22   LSHCi. 


CONTENTS 


PART   I 


THE   (ESOPHAGUS 

CHAPTER 

I.   SURGICAL  ANATOMY  AND  PHYSIOLOGY   . 


II. 
III. 


V. 

VI. 


X. 

XI. 


XII. 


INJURIES.     INTERNAL  AND  EXTERNAL  INJURY.     RUPTURE      . 

IMPACTION  OF  FOREIGN  BODIES  :  NATURE  OF  BODY  IMPACTED 
SEAT  OF  IMPACTION.  SYMPTOMS,  DIAGNOSIS,  PROGNOSIS 
TREATMENT    .  .  


INFLAMMATORY  AFFECTIONS  :  ACUTE  TRAUMATIC  (ESOPHAGITIS 
ACUTE  IDIOPATHIC  (ESOPHAGITIS  ;  CESOPHAGITIS  OF  CHIL 
DREN  ;  MEMBRANOUS  OR  PELLICULAR  (ESOPHAGITIS 
APHTHOUS  (ESOPHAGITIS  ;  CHRONIC  (ESOPHAGITIS  ;  PHLEG 
MONOUS  CESOPHAGITIS  ;  SUBMUCOUS  (ESOPHAGEAL  AB 
SCESSES  ;  CATARRHAL  (ESOPHAGITIS  ;  FOLLICULAR  (ESO 
PHAGITIS  ;    CROUPOUS   (ESOPHAGITIS       .... 

ULCER.      VARICOSE  VEINS.     SYPHILIS.     TUBERCULOSIS     . 

TUMOURS  :  INNOCENT — PAPILLOMA.     CYSTS.     FIBROMA.    ADENOMA, 
MYXOMA.     MYOMA.    LIPOMA 


VII.      TUMOURS  :  MALIGNANT — CARCINOMA  AND  SARCOMA  . 

VIII.     CARCINOMA  {continued),   prognosis  and  treatment 

IX.      NON-MALIGNANT    OR    CICATRICIAL    STRICTURE.    ETIOLOGY.     SYM 
PTOMS,    DIFFERENTIAL    DIAGNOSIS,    DIAGNOSIS,    PROGNOSIS 

CICATRICIAL  STRICTURE  {continued).      TREATMENT 

PARALYSIS     AND     SPASM.       ETIOLOGY,       SYMPTOMS,      DIAGNOSIS 
PROGNOSIS,    TREATMENT 

ABNORMALITIES  :         DILATATION.        DIVERTICULA.         CONGENITAL 
ATRESIA.     CONGENITAL  STENOSIS.     TORSION 

XIII.      ABNORMALITIES    {continued).    DIVERTICULA.    ETIOLOGY,    PATHO 
LOGY,  SYMPTOMS,  DIAGNOSIS,  PROGNOSIS,  TREATMENT     . 


PACK 
1 


16 


36 
46 

54 
58 
72 

84 
93 

103 

112 

117 


:      SURGEEY  OF  THE  ALIMENTARY  CANAL 

HAPTER  PAGE 

XIV.      ABNORMALITIES  (confmwe  J).   MALFORMATIONS  OR  DEFORMITIES. 

CONGENITAL  ATRESIA.    CONGENITAL   STENOSIS.     TORSION       .      125 
XV.      EXTERNAL  INFLUENCES  :  PRESSURE.    PERFORATION.   DISTORTION      130 

XVI.  OPERATIONS  :  1.  INTRODUCTION  OF  BOUGIES,  FORCEPS.  PRO- 
BANGS,  EXTRACTORS,  &C.  2.  INTERNAL  OESOPHAGOTOMY. 
3.  ELECTROLYSIS.  4.  EXTERNAL  (ESOPHAGOTOMY  (CER- 
VICAL). 5.  EXTERNAL  (ESOPHAGOTOMY  (tHORACIC).  6.  (ESO- 
PHAGOSTOMY.  7.  EXCISION  OF  DIVERTICULA.  8.  OiSOPHAGO- 
PLASTY,     9.    OSSOPHAGECTOMY 134 


XVII. 
XVIII. 


XX. 

XXI. 


XXIV. 


XXV. 
XXVI. 


PAET  II 

THE  STOMACH 

SURGICAL  ANATOMY  AND  PHYSIOLOGY 145 

METHODS  (1)  OF  OBTAINING  GASTRIC  JUICE  FOR  EXAMINA- 
TION :    (2)    FOR  DETECTION   OF   FREE    HYDROCHLORIC   ACID  : 

(3)  OF   ASCERTAINING  THE  RATE    OF   GASTRIC   ABSORPTION  : 

(4)  FOR  DETERMINING  THE  MOTOR  POWER  OF  THE  STOMACH. 
PHYSICAL  EXAMINATION  I  PALPATION ;  PERCUSSION  ; 
AUSCULTATION  ;  INFLATION  ;  GASTROSCOPY ;  GASTRO-DIA- 
PHANY 149 

INJURIES  :       CONTUSION,      TRAUMATIC      RUPTURE,      TRAUMATIC 

PERFORATION,  GUNSHOT  V^^OUND 156 

FOREIGN  BODIES.     GASTROLITHS.     HAIR  CONCRETIONS     .  .      .       164 

DISEASE.  EXPLORATORY  GASTROTOMY.  ULCER  :  ITS  CHA- 
RACTER,  AND    OCCURRENCE    OF   EXCESSIVE    HEMORRHAGE  .      173 

ULCER  {continued) :  perforation  :  its  treatment  by  (1)  ex- 
cision OF  THE  perforated  ULCER  :  (2)  BY  SIMPLE  SUTURE 
OF  THE  PERFORATION  :  (8)  BY  STITCHING  THE  SEAT  OF 
PERFORATION  TO  THE  ABDOMINAL  INCISION  :  (4)  BY  OPEN 
DRAINAGE.  TABLE  OF  CASES  SUCCESSFULLY  TREATED  BY 
OPERATION 181 

ULCER  {continued) :  formation  of  abscess  ;  fistulous  com- 
munications ;  external  adhesions  ;  ino'ernal  contrac- 
tion ;  PYLORIC  stenosis 192 

TUMOURS      IN      THE       BODY     OF     THE      STOMACH  :     INNOCENT  ; 

MALIGNANT 201 

OBSTRUCTION  AT  THE  CARDIAC  AND  PYLORIC  ORIFICES  .  .      207 

PYLORIC  OBSTRUCTION.  TREATMENT  {contimtcd).  PROGNOSIS 
IN  RESPECT  TO  THE  OPERATIONS  OF  PYLORECTOMY  :  GASTRO- 
ENTEROSTOMY: THE  COMBINED  OPERATION  OF  PYLORECTOMY 
AND  gastroenterostomy:  DIGITAL  DIVULSION  :  PYLORO- 
PLASTY ;  duodenostomy  :  jejunostomy  ;  and  curetting    218 


CONTENTS 


XI 


CHAPTER 
XXVII. 


PAGE 

gastric  dilatation.  conditions  dependent  upon  ex- 
ternal influences  such  as  adhesions,  tumours,  and 
systemic  diseases 224 

operations  :  1.  lavage.    2.  aspiration.    3.  gasteotomy. 

4.  gastrostomy:  egebert's  ;  hahn's;  witzel's  ;franks's. 

5.  GASTRECTOMY.  6.  GASTRORRHAPHY.  7.  GASTROPEXY  .   228 

OPERATIONS  (contimiecl)  :  8.  gastro-enterostomy  (gastro- 
jejunostomy, GASTRO-ILEOSTOMY,  GASTRO-COLOSTOMY)  : 
WOLFLER'S  ;  SENN'S.  SOURCE  OF  FAILURE  AND  TROUBLE- 
SOME AFTER  EFFECTS 248 

OPERATIONS  (continued)  :  9.  pylorectomy.  10.  pyloro- 
plasty (hEINEKE-MIKULICZ).  11.  PYLORIC  DIVULSION. 
(LORETA).       12.    CURETTING  (BERNAYS)        ....      260 


PAET  III 

THE  SMALL  AND  LARGE  INTESTINE 

SECTION  I 

THE    DUODENUM 

XXXI.       ANATOMY.     INJURIES  :  RUPTURE  ;  FOREIGN  BODIES 

XXXII.      DISEASE.     SIMPLE  OR  CHRONIC  ULCER.     ACUTE  ULCERATION  . 

XXXIII.  TUMOURS  :  INNOCENT  AND  MALIGNANT.  STRICTURE.  CON- 
GENITAL STENOSIS  AND  OBLITERATION.  PERFORATION 
FROM  EXTERNAL  CAUSES        


271 

277 

288 


xxxiv.     operations  :   duodeno.stomy.   duodenectomy.   duodeno- 

tomy.  duodenoplasty 295 


SECTION   II 


THE    JEJUNUM    AND    ILEUM 


XXXV.     anatomy  and  physiology 


XXXVI.      INJURIES.     CONTUSION  :     ACUTE     AND     CHRONIC    ENTERITIS, 
ULCERATION  AND  SLOUGHING,  STRICTURE.      RUPTURE 


297 
300 


XXXVII.     INJURIES  (continued),    punctured  and  incised  wounds. 

NATURE  OF  LESION.   SYMPTOMS,  PROGNOSIS,  TREATMENT  .   313 

xxxviii.     INJURIES    (continued),     gun-   and   pistol-shot  wounds. 

NATURE  OF  LESION.  SYMPTOMS,  PROGNOSIS,  TREATMENT  .   319 

XXXIX.   FOREIGN  BODIES  :  THEIR  NATURE,  AND  COURSE  TAKEN  IN 

PROCESS  OF  NATURAL  EXPULSION.  SYMPTOMS,  TREATMENT   328 


xu 


SURGERY  OF  THE  ALIMENTARY  CANAL 


CHAPTER 

XL. 


LI. 


XLIII. 


XLV. 


XLVI. 


XLVII. 


XL  VIII. 


XLIX. 


TUBERCULAR  ULCERATION  :  SYMPTOMS  AND  TREATMENT 
TYPHOID  ULCERATION  :  SYMPTOMS  AND  TREATMENT 
OPERATION         ,  .  .  

OBSTRUCTION.  INTERNAL  HERNIA  (a)  INTO  NORMAL  PERI 
TONEAL  FOSS^.  (b)  STRANGULATION  THROUGH  ADVENTI 
TIOUS  OR  CONGENITAL  APERTURES  .... 

OBSTRUCTION  {continued),    internal  hernia  {continued) 

(C)  UNDER  BANDS,  CORDS,  AND  DIVERTICULA.  STRANGU- 
LATION PRODUCED  BY  NORMAL  STRUCTURES,  AS  THE  VERMI- 
FORM APPENDIX,  THE  APPENDICES  EPIPLOIC^,  AND  THE 
FALLOPIAN  TUBE.  METHOD  BY  WHICH  STRANGULATION 
BENEATH  A  BAND  IS  EFFECTED.  SYMPTOMS,  DIAGNOSIS, 
TREATMENT       ......... 

OBSTRUCTION  {continued),  adhesions,  kinking,  symptoms 

AND  TREATMENT 

OBSTRUCTION  {continued),  intussusception.  patho- 
logical ANATOMY  :  the  ILEO-C^GAL,  ENTERIC,  AND  ILEO- 
COLIC VARIETIES.  THE  INDIRECT  AND  DIRECT  CAUSES  OF 
OBSTRUCTION.     SYMPTOMS 

OBSTRUCTION  {continued),    intussusception  {continued). 

TREATMENT  :  I.  OF  ACUTE  CASES  SEEN  WITHIN  FORTY- 
EIGHT  hours  ;  II.  OF  ACUTE  CASES  NOT  SEEN  TILL  AFTER 
FORTY-EIGHT  HOURS  ;  III.  OF  SUBACUTE  CASES  ;  IV.  OF 
CHRONIC   CASES 

OBSTRUCTION    {continued),     volvulus,      symptoms    and 

TREATMENT      .  

OBSTRUCTION  {continued),    stricture  :   its   nature  and 

PATHOLOGICAL   SEQUELS.     SYMPTOMS.     TREATMENT         .      . 

OBSTRUCTION  {continued),    gall-stones,     symptoms,  pro- 
gnosis,   TREATMENT,     OPERATION, 
TIONS    OR   ENTEROLITHS    . 


339 


349 


INTESTINAL   CONCRE- 


TUMOURS  OF  THE  BOWEL  WALL.  INNOCENT  :  FIBROMA, 
MYOMA,  ADENOMA,  LIPOMA,  CYSTS.  MALIGNANT  :  CAR- 
CINOMA :  SYMPTOMS  AND  TREATMENT.  SARCOMA  :  SYM- 
PTOMS  AND    TREATMENT         

L.      EXTERNAL  PRESSURE.    PERITONITIS,  ENTERITIS.    CONGENITAL 
ABNORMALITIES,    MALDEVELOPMENTS.      NEUROSES 

SECTION  III 

THE    LARGE    INTESTINE    AND    APPENDIX   VERMIFOEMIS 


LI.      ANATOMY  AND  PHYSIOLOGY 
LII. 


354 

868 
371 

382 
389 
393 

401 

410 
417 

425 


INJURIES.     INFLAMMATION.     ULCERATION  :      TYPHOID   ULCER, 
TUBERCULAR      ULCER,      DYSENTERIC      ULCER,       GENERAL 


CONTENTS 


XUl 


SYMPTOMS, 


ulcerative  colitis,  ulcer  from  obstruction,  ster- 
coral ulcers,  ulcers  following  upon  lesion  of  the 
spinal  cord,  syphilitic  ulcers,  catarrhal  ulcers 

non-malignant    or    cicatricial     stricture 

diagnosis,  treatment 

internal  strangulation  :  diaphragmatic  hernia.  adhb 
signs.  kinking.  intussusception.  symptoms,  dia 
gnosis,  prognosis,  and  treatment.  volvulus  :  sym 
ptoms  and  treatment         ...... 

gall-stones,  enteroliths  :  symptoms.  f^cal  accumu 
lation  :  symptoms  and  treatment 

tumours:    innocent:    papilloma    and  adenoma,   fibroma 
and  fibro-myoma,  lipoma,  dermoids,  cysts.  malignant 
carcinoma  :  pathology  and  symptoms 

CARCINOMA  (contimied).    diagnosis,  prognosis,  treatment 

SARCOMA    


IDIOPATHIC  DILATATION  :  TREATMENT.  ABNORMALITIES  :  MIS 
PLACEMENTS  !  1.  OF  THE  WHOLE  BOWEL  ;  2.  OF  THE 
C^CUM  ;  3.  OF  THE  SIGMOID  FLEXURE.  MALDEVELOPMENT 
ABNORMALITIES   OF   THE    ILEO-CiECAL   VALVE 

EMBOLISM    AND    THROMBOSIS     OF    THE    MESENTERIC   VESSELS 
SYMPTOMS.        THROMBOSIS    OF   THE    SUPERIOR   MESENTERIC 
VEIN 


LX.      THE    VERMIFORM  APPENDIX  :  ANATOMY.     APPENDICITIS  :    PATHO 
LOGY   AND    ETIOLOGY       

LXI.     APPENDICITIS  (continued)  :    symptoms  and  diagnosis  . 

jLxii.  APPENDICITIS  (continued)  :  prognosis  regarding  the 
disease,  and  regarding  operation,    treatment 

LXiii.  appendicitis  (continued).  operation:  in  cases  of 
1.  abscess  ;  2.  fistula  ;  3.  adhesions  of  the  appendix 
without  an  exudation  ;  4.  adhesions  with  an  exu- 
dation ;  5.  perforation  and  peritonitis.  other 
diseases  of  the  appendix:  cysts,  malignant  disease 

lxiv.  operations  upon  the  small  and  large  intestine, 
terminology.      list     of      operations,      enterotomy. 

ENTEROSTOMY  :  NELATON's  OPERATION.  JEJUNOSTOMY  I 
JESSETT'S  MODIFICATION,  MAYDL's  MODIFICATION,  ALBERT'S 
MODIFICATION.       ILEOSTOMY         ...... 

Lxv.  OPERATIONS  (continued)  :  enterectomy.  entero-anasto- 
Mosis :  1.  end-to-end  union  ;  2.  lateral  approxima- 
tion ;  3.  LATERAL  IMPLANTATION.  METHODS  OF  UNITING 
BOWEL  :  A.  UNION  BY  SUTURE  :  1.  THE  CIRCULAR,  (a)  THE 
CZERNY-LEMBERT,       (6)      BISHOP'S      SUTURE  ;        2.      ABBE'S 


430 
438 

444 
453 

461 
471 

477 

486 

489 
497 

506 
513 

518 


XIV 


SURGERY   OF   THE   ALIMENTARY   CANAL 


SUTURE  ;  3.  maunsell's  suture  ;  4.  halsted's  suture. 

B.  UNION  BY  PLATES  :  SENN'S  METHOD.  C.  UNION  BY 
tubes:  PAUL'S  METHOD  ;  ROBINSON'S  METHOD.  D.UNION 
BY  BONE  BOBBINS  :  ROBSON'S  METHOD.  E.  UNION  BY 
METAL  BUTTONS  I  MURPHY's  METHOD.  F.  UNION  BY 
RINGS  :  abbe's  METHOD.  G.  OTHER  METHODS  OF  UNION, 
BY   CLAMPS 526 

Lxvi.  OPERATIONS  {continued) :  entero-enterostomy  (short- 
circuiting).  fiNTEROPLASTY.  COLOTOMY.  COLOSTOMY  I 
LUMBAR,  INGUINAL,  SIGMOIDOSTOMY.  COLECTOMY  :  PAUL's 
METHOD.    BARACZ'S  OPERATION.     COLOPEXY  .  .  .      543 

Lxvii.     OPERATIONS  {continued)  :  artificial  anus  ;  sigmoid  anus. 

CRIPPS'S  OPERATION.  LUMBAR  ANUS.  CLOSURE  OF  F^CAL 
fistula   and   ARTIFICIAL  ANUS  :    CHAPUT'S  OPERATION        .      550 

Lxviii.  OPERATIONS  (continued) :  appendicectomy  :  the  skin 
incision  ;  to  find  the  appendix  ;  to  remove  the 
appendix  :  treves's  method,  barker's  method.  other 
operations  involving  some  part  of  the  bowel  : 
gastro-enterostomy  ;  cholecyst-enterostomy  ;  ure- 
tero-enterostomy  ;  cyst-enterostomy  .        .        .     .     556 


PAET   IV 

THE  BECTUM 


LXIX.      ANATOMY  AND    PHYSIOLOGY.     SURGICAL   ANATOMY.     METHODS 

OF  EXAMINATION        ........      561 

LXX.  INJURIES.  NATURE  AND  RESULTS  OF  INJURY.  SYMPTOMS, 
TREATMENT.  FOREIGN  BODIES.  F^CAL  CONCRETIONS. 
SYMPTOMS,    DIAGNOSIS,    PROGNOSIS,    TREATMENT    .  .      .      567 

LXXI.  DISEASE.  INFLAMMATION  :  PROCTITIS  :  SYMPTOMS  AND  TREAT- 
MENT. PERIPROCTITIS.  NON-MALIGNANT  ULCERATION  : 
DYSENTERIC  ULCERATION,  TUBERCULAR  ULCERATION, 
SYPHILITIC  ULCERATION,  VARICOSE  ULCER,  ULCERATION 
FROM    OTHER   CAUSES.       SYMPTOMS   AND    TREATMENT  .      577 

LXXII.  NON-MALIGNANT  OR  CICATRICIAL  STRICTURE  :  PATHOLOGICAL 
SEQUENCES.  SYMPTOMS,  DIAGNOSIS,  PROGNOSIS,  TREAT- 
MENT 1.  BY  BOUGIES  ;  2.  BY  ELECTROLYSIS  ;  3.  BY 
INTERNAL  PROCTOTOMY  ;  4,  BY  EXTERNAL  OR  LINEAR 
PROCTOTOMY  ;    5.    BY   EXCISION  ;    6.    BY    ARTIFICIAL   ANUS  .      590 

XXIII.  TUMOURS  :  INNOCENT  :  POLYPUS.  ADENOMA,  FIBROMA,  PAPIL- 
LOMA, LYMPHOMA,  MYOMA,  MYXOMA,  LIPOMA,  CYSTOMA, 
TERATOMA,  ANGEIOMA.  SYMPTOMS,  DIAGNOSIS,  PROGNOSIS, 
TREATMENT 601 


CONTENTS 


XV 


cHAP'ran  PAGE 

Lxxiv.     TUMOURS  {continued) :  malignant  :  carcinoma  :  pathology, 

PROGRESS    OF   THE    DISEASE 612 

Lxxv.     CARCINOMA  (continued) :  symptoms,  diagnosis,  prognosis 

IN  REGARD  TO  THE  OPERATION  :  1.  OF  EXCISION  THROUGH 
THE  PERINEUM  ;  2.  OF  EXCISION  THROUGH  THE  SACRUM  ; 
3.    OF   THE    FORMATION   OF   AN   ARTIFICIAL   ANUS         .  .      619 

Lxxvi.     CARCINOMA  {continued) :  treatment  :  1.  of  non-operable 

CASES ;  2.  of  operable  CASES,    sarcoma  .         .        .     .     631 

LXXVII.      prolapse  :    etiology,  symptoms,    TREATMENT   IN   CHILDREN      637 

Lxxviii.     PROLAPSE   {continued)  :    treatment    in    adults  :    1.   by 
CLAMP  and  cautery  ;  2.  BY  cautery  ;  3.  BY  elliptical 

INCISIONS  :  ROBERTS'S  OPERATION ;  4.  BY  AMPUTATION  : 
(A)  MIKULICZ'S  METHOD,  (B)  TREVES'S  METHOD,  (C) 
KLEBERG'S  METHOD  ;  5.  BY  ELEVATION  AND  FIXATION  : 
(A)  VERNEUIL'S  METHOD,  (B)  M'LEOD'S  METHOD,  (C)  BY 
PRELIMINARY  LAPAROTOMY.  LANGE'S  METHOD.  INTUS- 
SUSCEPTION.    RECTAL   HERNIA.     RECTOCELE       .  .  .      642 

LXXIX.  MALFORMATIONS:  PATHOLOGY,  SYMPTOMS,  DIAGNOSIS,  PRO- 
GNOSIS IN  REGARD  TO  THE  DISEASE,  AND  TO  OPERATION     .      654 

LXXX.      MALFORMATIONS     {continued)  :     TREATMENT.       CONGENITAL 

STRICTURE.    DIVERTICULUM 664 

LXXXI.      NEUROSES.     EXTERNAL   INFLUENCES    PRODUCING   PRESSURE, 

DISPLACEMENT    OR   DISTORTION,  AND    PERFORATION    .  .      672 

LXXXII.  OPERATIONS.  THE  ADMINISTRATION  OF  COPIOUS  FLUID 
ENEMATA.  THE  PASSAGE  OF  BOUGIES  &C.  ;  INTERNAL 
PROCTOTOMY.  EXTERNAL  PROCTOTOMY.  PROCTECTOMY  : 
PERINEAL 676 

Lxxxiii.     0-p^B.ATioiis  (continued) :  sacral  proctectomy,  kraske's 

OPERATION.  MODIFICATIONS  INTRODUCED  BY  HEINEKE, 
KOCHER,  LEVY,  HEGAR,  REHN  (REHN-RYDYGIER),  BORELIUS. 
PARA-SACRAL  METHOD  (ZUCKERKANDL  AND  WOLFLER). 
METHODS  OF  TREATING  THE  BOWEL  AFTER  EXCISION 
TO  OBTAIN  SPHINCTER  ACTION,  BY  LANGE,  WILLEMS, 
WITZEL,  GERSUNY.  AFTER  TREATMENT.  VAGINAL  PROCTEC- 
TOMY. METHODS  FOR  HIGH  REMOVAL  OF  DISEASE,  BY  MAUN- 
SELL'S  SUTURE,  BY  UHLMANN,  BY  BACON.  PROCTORRHAPHY. 
PROCTOPEXY.  PROCTOPLASTY.  RECTAL  ELECTROLYSIS. 
RECTAL   CAUTERISATION 683 

LXXXIV.  RECTAL  ADMINISTRATIONS.  NUTRITIVE  ENEMATA  :  VARIOUS 
KINDS  AND  MODE  OF  ADMINISTRATION.  THERAPEUTIC 
ENEMATA  :  PURGATIVE,  ANTHELMINTIC,  ASTRINGENT,  SEDA- 
TIVE      693 

INDEX    OF   NAMES 699 

INDEX    OF    SUBJECTS 707 


LIST   OF   CASE  EEPOETS 


(ESOPHAGUS 

XO.  OP  CASE  PARK 

I.     A  diffuse  perioesophageal  abscess  in  a  '  sword  swallower  '  .         6 
II.     Eupture  produced  by  vomiting 10 

III.  Rupture  during  a   violent  endeavour  to  dislodge  an  im- 

pacted mass  of  food.     Death  from  exhaustion  in  seven 

and  a  half  days       ........       11 

IV.  Eupture  during  vomiting  after  a  heavy  meal.     Death  in 

seven  hours         .         .         .         .         .         .         .         .     .       12 

V.     Eupture  :   softening  of  the  walls  by  gastric  solution  just 

prior  to  death 12 

VI.     Eupture  where  the  walls  had  become  softened  by  gastric 

solution       ..........       13 

VII.     Coin    impacted :    symptoms     not     urgent     at    first,    but 

developing  later      ........       19 

VIII.     Impaction  of  a  piece  of  meat.     Death  from  dyspncBa  caused 

by  abscess  .........       20 

IX.     Perforation  by  a  fish  bone.     Post-oesophageal  abscess,  and 

death  from  pyiemia         .......       21 

X.     Impaction  of  a  mass  of  meat,  and  perforation  by  a  piece 

of  bone.     Extensive  emphysema  and  death        .         .     .       21 
XI.     Perforation   of    the    aorta  by  a  piece   of   impacted  bone. 

Death  from  haemorrhage 22 

XII.     Perforation   by    an    impacted    fish    bone.       Death    from 

injury  to  the  heart     .         .         .         .         .         .         .     .       22 

XIII.  Impaction  of  a  fish  bone :  perforation  of  an  intervertebral 

substance  and  injury  to  the  spinal  cord  ...       23 

XIV.  Impaction  of  a  coin  :  expulsion  by  the  mouth  after  four 

months       ..........       26 

XV.     Impaction  of  a  toothplate  :  expulsion  by  the  mouth  after 

fifteen  months         ........       26 

XVI.      Impaction    of     a    toothplate :    expulsion  ^;>er    anum   five 

months  afterwards      .         .         .         .         .         .         .     .       27 

XVII.  Impaction  of  a  five-centime  piece.  Death  from  scarlet 
fever  twenty  months  afterwards.  Coin  foixnd  partially 
encysted .27 


LIST   OF   CASE   REPORTS 


XVU 


NO.  OF  CASE 

XVIII. 

XIX. 

XX. 

XXI. 

XXII. 


XXIII. 
XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 

XXX. 

XXXI. 

xxxn. 

XXXIII. 

XXXIV. 

XXXV. 

XXXVI. 

XXXVII. 
XXXVIII. 

XXXIX. 

XL. 

XLI. 

XLII. 

XLIIL 

XLIV. 


Impaction  of  a  chestnut.     Death  from  acute  phthisis 

fourteen  months  afterwards.  Chestnut  found  encysted 
Impaction  of  a  piece  of  bone  :  ejection  of  the  bone  by 

induction  of  vomiting    ....... 

Impaction  of  the  heart  of  a  bird  :  subcutaneous  injection 

of  ^  grain  of  tartar  emetic  :  ejection  of  the  substance 

by  vomiting       ........ 

Impaction  of  a  piece  of  bone  :  subcutaneous  injection 

of  -^  grain  of  apomorphia :  ejection  of  the  bone  by 

vomiting        .... 
Rupture  of  the  aorta,  the  result  of  an  endeavour  to  force 

onwards,  by  means  of  a  probang,  an  impacted  tooth 

plate  ..... 

Extraction  of  an  impacted  fish  hook 
Impaction  of  a  peach  stone  :  successful  removal  tlirough 

the  mouth  by  the  aid  of  gastrotomy 
Impaction  of  false  teeth :  successful  removal  through 

the  mouth  by  the  aid  of  gastrotomy 
Acute  oesophagitis    the  result  of  a   sting   of  a  wasp 

Recovery  in  nine  days 
Aciite  idiopathic  oesophagitis     . 
OEsophagitis  in  a  child  . 
Diphtheritic  oesophagitis  . 
Chronic  oesophagitis 
Simple  ulcer  leading  to  stricture 
Varix.     Death  from  haemorrhage  . 
Fatal  haemorrhage  from  varicose  veins 
Polypus  ..... 

Carcinoma  :  gastrostomy  :  survival  for 
Syphilitic  stenosis 
Forcible  dilatation  of  cicatricial  stricture  with  bougies 
Cicatricial  stricture  treated  by  gastrostomy,  and  sub 

sequent  dilatation  with  bougies    .... 

Spasm  due  to  gout  ...... 

Dilatation  supervening  upon  a  fall    .... 

Pressure  diverticulum  situated  in  the  neck   . 
Congenital  atresia      ....... 

Congenital  atresia  ....... 

Congenital  stricture  ....... 


407  days 


27 
29 

30 

30 


32 
34 

36 

30 

38 
40 
41 
42 
45 
48 
51 
51 
57 
82 
88 
96 

103 
111 
116 
125 
128 
128 
129 


STOMACH 

XLV.     Rupture  of  the  stomach  and  spleen.     Death  .         .     161 

XLVI.     Pistol-shot  wound :  suture  of  wounds.     Recovery     .     .     164 
XLVII.     The  existence  of  a  razor  in  the  stomach.     Gastrotomj'. 

Death  from  haemophilia         .         .         .         .         .     .     171 

XLVIII.     Exploratory  gastrotomy  for   supposed  ulcer :   nothing 

found,  but  patient  completely  restored  to  health       .     174 

a 


xviii         SURGERY   OF   THE   ALIMENTARY   CANAL 


NO.  OF  CASE 

XLIX. 


LI. 


LII. 


LIII. 
LIV, 


LV. 


Exploratory  gastrotomy  for  supposed  disease :  nothing 
found,  but  patient  completely  restored  to  health       .     . 

Perforation  of  gastric  ulcer :  laparotomy  :  suture  of  per- 
foration.    Recovery      ....... 

Perforation  of  gastric  ulcer:  laparotomy  and  fixation 
of  the  gastric  opening  to  the  edge  of  the  parietal 
incision.     Death  on  the  sixth  day 

Gastric  ulcer  with  formation  of  subphrenic  abscess : 
operation.  Recovery.  Death  subsequently  from  septi- 
caemia .......... 

Gastric  ulcer  vv^ith  gastro-colic  sinus 

Carcinoma  of  pylorus :  gastro-enterostomy.  Death  on 
the  ninth  day  from  inanition  the  result  of  a  gastric 
fistula 211 

Carcinoma  of  pylorus  :  gastro-enterostomy.  Death  on 
the  fourth  day  from  uraemia     .         .         .         .         .     .     211 


175 


190 


191 


195 
197 


DUODENUM 

LVI.     Traumatic  rupture  of  the  third  part  of  the  duodenum     .  276 

LVII.     Simple  ulcer.     Death  from  perforation     ....  281 

LVIII.     Simple  ulcer :  no  symptoms  until  perforation      .         .     .  282 

LIX.     Ulceration  after  a  burn     .......  288 


JEJUNUM  AND  ILEUM 

LX.     Acute   obstruction   from   cicatricial   contraction    of  the 

bowel  following  upon  injury     .         .         .         .         .     .     301 

LXI.     Ulceration  and  perforation  above  a  traumatic  stricture 

of  the  jejunum 302 

LXII.     Rupture   of    the    jejunum    at    its    middle.     Death    in 

twenty-eight  hours 309 

LXIII.     Stab  wound   of   the    abdomen,   with  multiple  wounds 
of     the    intestine :    laparotomy :    intestinal     suture. 
Recovery       .........     318 

LXIV.     Pistol-shot  wound  of  the  small   intestine  :   seven   per- 
forations :  suture.    Recovery    .         .         .         .         .     .     327 

LXV.     Revolver-shot  wound  of  the   intestine   and  mesentery : 

five  perforations :  suture.    Recovery     ....     328 

LXVI.     Perforation  of  the  bowel  by  a  crown  of  a  species  of 

spear  grass :  acute  peritonitis.    Death     .         .         .     .     332 

LXVII.     Perforation  of  the  bowel  by  a  fish  bone :  formation  of 

intra-abdominal  abscess ;  opened.     Recovery       .         .     334 
LXVIII.     Passage    of    a    portion   of    a    rabbit's    femur   into  the 

bladder :  expulsion  per  urethram.     Recovery  .     .     335 

LXIX.     Temporary  intestinal   obstruction   from  ingestion   of  a 

quantity  of  gooseberry  skins 337 


LIST   01'   CASE   REPORTS 


XIX 


NO.  OF  TASK  TAffK 

LXX.     Wandering  and  encysted  needles  .....     338 

LXXI.     Perforation  of  a  typhoid  ulcer :  laparotomy  :  suture 

of  the  perforation.    Recovery         ....     347 

LXXII.     Perforation  of  a  typhoid  ulcer  :  laparotomy  :  suture 

of  the  perforation.     Recovery   .         ....     348 

LXXIII.     Hernia  of  a  portion  of  the  ileum  into  the  fossa  duo- 

deno-jejunalis:  strangulation:  laparotomy.   Death     351 
LXXIV.     Strangulation  of  the  ileum  through  an  aperture  in  the 

mesentery :  operation.     Death      ....     352 

LXXV.     Intestinal  obstruction  due   to   the  occlusion  of  the 

ileum  by  a  band :  operation.     Recovery  .         .     .     366 
LXXVI.     Acute  intestinal   obstruction  produced  by  Meckel's 

diverticulum.    Death     ......     367 

LXXVIL     Acute  intestinal  obstruction  from  constricting  adhe- 
sions the  result  of  repeated  attacks  of  appendi- 
citis :      laparotomy :     separation     of     adhesions. 
Recovery  .........     371 

LXXVIII.     Ileo-caecal   intussusception :   laparotomy :   reduction. 

Recovery        ........     382 

LXXIX.     Intussusception.    Successful  reduction  by  inflation     .     383 
LXXX.     Intussusception  treated  by  injection  :  rupture.    Death     384 
LXXXI.     Subacute    intussusception:    seven   weeks'  duration: 

laparotomy:  reduction.      Recovery       .         .         .     388 
LXXXII.     Volvulus  of  ileum  the  result  of  traumatism  :  laparo- 
tomy :  untvi^isting.    Recovery 392 

LXXXIII.     Tubercular     stricture    of    the    intestine :     excision. 

Recovery        ........     394 

LXXXIV.     Stricture  of  ileum,  secondary  to  ulceration  produced 
by  strangulation  of  the  bowel  in  a  femoral  hernia  : 

perforation.    Death 395 

I XXXV.     Simple  stricture  of  the  small  intestine  at  junction  of 

jejunum  and  ileum  :  enteroplasty.     Recovery       .     396 
LXXXVI.     Gall-stone     causing     acute    intestinal    obstruction : 

entero-lithotomy.    Recovery     .....     408 

LXXXVII.     Intestinal  concretion  causing  prolonged  symptoms  of 

obstinate  constipation    ......     409 

LXXXVIII.     Spontaneous  disappearance  of  a  solid  tumour  of  the 

intestines  causing  obstruction.     Enterostomy  .     .     412 


LABGE  INTESTINE 

LXXXIX.     Simple  ulcer  of  sigmoid  flexure  .         .         .         .         • 

XC.     Simple  stricture  of  sigmoid  flexure  ...         .     • 

XCI.     Strangulated   diaphragmatic   hernia ;    symptoms    of 

acute  intestinal  obstruction  :  laparotomy.     Death 

XCII.     Volvulus  of  sigmoid  flexure,  successfully  reduced  after 

laparotomy    .,.,..'• 


433 
441 

445 


451 


XX 


SURGERY  OF  THE  ALIMENTARY  CANAL 


NO.  OF  CAPE  PAGE 

XCIII.     Two  enteroliths  in  the  colon,  successfully  removed  by 

colotomy       .........     454 

XCIV.     Chronic  constipation,  causing  dilatation  and  rupture  of 
the  sigmoid  flexure    ...... 

XCV.     Acute   intestinal  obstruction   caused  by  faecal  accumu 
lation :  colostomy.    Recovery       .... 

XCVI.     Carcinoma  of  the  ascending  colon  causing  chronic  ob- 
struction :  colectomy.     Recovery 
XCVII.     Carcinoma   at  the  junction  of  the  csecum  and  ascend 
ing   colon    causing  acute   obstruction :    colostomy 
intestinal  anastomosis.     Death  three  months  after 
from  exhaustion    ....... 

XCVIII.     Congenital  dilatation  of  the  colon.    Death 

XCIX.     Embolism  of  the  inferior  mesenteric  artery,  with  sym 
ptoms  of  obstruction  :  laparotomy.    Death  . 
C.     Acute      appendicitis ;      abscess     formation :      incision 
Recovery  ........ 

CI.     Relapsing  appendicitis  :  appendicectomy.    Recovery 


457 


460 


472 


473 
480 

488 

504 
505 


BECTUM 


CII. 

cm. 

CIV. 

cv. 
cvi. 

CVIL 
CVIII. 

CIX. 

ex. 

CXI. 

CXII. 

CXIII. 
CXIV. 

cxv. 


CXVI, 


Injury  to  rectum  :  abscess  formation.    Recovery     .         .     570 
Impaction   of    seeds,    fruit    stones,    and  husks    in   the 

rectum  :  acute  proctitis  :  removal.     Recovery  .         .     576 
Acute  proctitis  the  result  of  taking  large  doses  of  patent 

cathartic  remedies         ..>....     579 
Dysenteric  ulceration  of  the  rectum         ....     583 

Tubercular  ulceration  of  the  rectum 584 

Simple  ulcer  of  the  rectum  due  to  varicose  veins    .         .     585 
Non-malignant   stricture  of  the   rectum :   linear  proc- 
totomy.   Recovery        .         .         .         .         .         .     .     597 

Papilloma  or  villous  tumour  of  the  rectum      .         .         .     601 
Illustrating  the  bad  effects  of  perineal  excision  of  the 

rectum  .         .         .         .         .         .         .         ...     624 

Posterior  proctectomy  (Kraske).     Recovery  with  sacral 

anus  ..........     634 

Carcinoma  of  rectum :  sigmoid  anus.    Recovery         .     .     635 

Intussusception  of  the  rectum 653 

Rectal  hernia       .........     654 

Anal    cul-de-sac,    but   rectum    nnperforate  :     sigmoid 
anus :     subsequent     opening     into     rectum     from 
perineum.      Death  in  seven  months   from   scarlet 
fever  .         .         .         .         .         .         .        .        .     669 

Double  stricture  of  the  rectum   from  pelvic  celhilitis : 

acute  obstruction.     Death 675 


TABLES   OF   SUCCESSFUL  OPERATIONS  xxi 


LIST  OF  TABLES  OF  SUCCESSFUL  OPEEATIONS  FOB 
PEBFOBATION  OF  GASTBIC  ULCEB  AND  ACUTE 
INTESTINAL   OBSTBUCTION 

Table  of  cases  of  perforation  of  gastric  ulcer  successfully  treated 
by  operation  since  1891  .........     188 

Table  of  successful  operations  for  internal  strangulation  from 
1891  to  1895  inclusive 362 

Table  of  successful  cases  of  laparotomy  for  intussusception  from 
1891  to  1895  inclusive 385 

Table  of  successful  cases  of  laparotomy  for  volvulus  of  small 
intestine  from  1891  to  1895  inclusive         .         .         .         .         .     .     392 

Table  of  successful  cases  of  entero-lithotomy  for  impacted  gall- 
stones causing  intestinal  obstruction,  from  1891  to  1895 
inclusive 408 


LIST  OF  ILLUSTEATIONS 


[R.I.M.Glas  =  Royal  Infirmary  Museum,  Glasgow.    W.I.M.  =  Western 
Infirmary  Museum.     V.I.M.  =  Victoria  Infirmary  Museum.] 


PLATE 

FIG. 

I. 

1. 

II. 

2. 

III. 

7. 

IV. 

8. 

V. 

9. 

VI. 

13. 

VII. 

14. 

15. 


IX. 

■    16. 
,    17. 

X. 

18. 

XI. 

41. 

XII. 

42. 

XIII. 

43. 

XIV. 

44. 

XV. 

47. 

XVI. 

49. 

XVII. 

.52. 

XVIII. 

55. 

XIX. 

57. 

XX. 

58. 

XXI. 

59. 

XXII. 

60. 

XXIII. 

61. 

xxrv. 

63. 

XXV. 

64. 

XXVI. 

99. 

XXVII. 

104. 

LIST  OF  PLATES 

PA  Git 

HALF-CROWN   IMPACTED   IN    THE    (ESOPHAGUS  .  .  19 

A   HALFPENNY   IMPACTED    IN    THE    (ESOPHAGUS    .  .       .  24 

CARCINOMA   OF   THE    (ESOPHAGUS  CAUSING   PERFORATION 

AND    GANGRENE    OF   LUNG 60 

CARCINOMA   OF   THE  (ESOPHAGUS  NEAR   CARDIAC  ORIFICE  68 
CARCINOMA  OF    THE  (ESOPHAGUS  PRODUCING  DILATATION 

ABOVE 74 

DIVERTICULUM    OF   THE    (ESOPHAGUS        ....  118 
PERFORATING   ULCER  OF   STOMACH    SITUATED   IN  LESSER 

CURVATURE 176 

CHRONIC   ULCERS     OF     STOMACH,     HEALED    AND     PERFO- 
RATING   .........  180 

CARCINOMA   OF   STOMACH ]  c^r.. 

Y  204 
carcinoma  of  stomach   .    .    .    .    .    ) 

carcinoma  of  pylorus  .......  212 

perforating  ulcer  of  duodenum  .   j    .    .  278 

perforating  ulcer  of  duodenum    .    ...  280 

perforating  ulcer  of  duodenum  ....  282 

rupture  of  jejunum   .    .    .    .    .    .  .  306 

typhoid  ulceration  and  perforation   .    .    .  342 

Meckel's  diverticulum ;  358 

iLEO-CiECAL  intussusception       .         .         .         .         .  376 

stricture  of  small  intestine 394 

diaphragmatic  hernia 446 

cylinder-celled   carcinoma   of   transverse   colon  466 

carcinoma  of  colon  causing  stricture        .         .     .  468 

colloid  carcinoma  of  sigmoid  flexure   .         .         .  470 

round-celled  sarcoma  of  large  intestine        .     .  476 

perforation  of  vermiform  appendix         .         .         .  502 

cystic  vermiform  appendix 517 

chronic  ulceration  of  entire  rectum  .         .         .  582 

colloid  carcinoma  of  rectum      .        .  615' 


JESSETT'S   mode    of   fixing    the    STOMiCH    IN    GASTROSTOMY      .      237 


FRANKS'S   METHOD    OF   PERFORMING    GASTROSTOMY  .  .      .      245 


LIST  OF   ILLUSTRATIONS  Xxiii 

LIST  OF  FIGUBES  IN  TEXT 

FIO.  TAdK 

3.  BRISTLE    PROBANG 81 

4.  COIN   CATCHER 32 

5.  CESOPHAGEAL   FORCEPS   WITH    PERPENDICULAR   CURVE  .  .  33 

6.  SIMPLE    PERFORATING   ULCER    OF   THE    (ESOPHAGUS  .  .       .  47 

10.  SYMONDS'S    SHORT    TUBE    FOR   CANCER   OF    THE    (ESOPHAGUS  .  70 

11.  SYMONDS'S    SHORT    TUBE    WITH   INTRODUCERS    READY   FOR   USE    .  76 

12.  SYMONDS'S  SHORT  TUBE  {in  situ)       ......       76 

19.      DIAGRAM    SHOWING   LINES    OF   INCISION   ADOPTED    RESPECTIVELY 

BY   VON   HACKER,    FENGER,    AND    HAHN,    FOR    GASTROSTOMY      .      233 
20.]    GREIG     smith's     MODE     OF    FIXING   THE    STOMACH     IN     GASTRO- 
21.  [  STOMY 235 

22.' 
23. 

24.  ^ 

25.  )-   WITZEL'S   METHOD    OF   PERFORMING   GASTROSTOMY       .  .  .      243 
26.) 

27. 
28. 

29.  barker's  METHOD  OF  CLAMPING  INTESTINE  WITH    RUBBER    TUBE      250 

30.  >! 

31.  f    MAYLARD'S   METHOD    OF     CLAMPING    INTESTINE   WITH     RUBBER- 

32.  [  PROTECTED   DISSECTING   FORCEPS        .  .  .  .  .  250,  251 

33.) 

34.   SENN'S  DECALCIFIED  BONE  PLATE  READY  FOR  USE  .     .     .   254 
85.] 

36.) 
37. 
38. 
39.1 
40. ) 

45.  PISTOL-SHOT    WOUND    OF    SMALL   INTESTINE 321 

46.  TUBERCULAR   ULCER   OF   INTESTINE 340 

48.      STRANGULATION    OF   A   LOOP  OF   SMALL  INTESTINE  BY   A  FIBROUS 

BAND 355 

50.  STRANGULATION     OF     A    LOOP     OF   SMALL     INTESTINE     BENEATH 

MECKEL'S   DIVERTICULUM 357 

51.  DIAGRAM   OF   A   LONGITUDINAL  SECTION  OF  AN  INTUSSUSCEPTION      373 

53.  ILEO-CiECAL   INTUSSUSCEPTION 374 

54.  INTUSSUSCEPTION.       A   SLOUGH   OF   ILEUM   PASSED    PER    RECTUM  378 

56.      ILEO-C^ECAL   VALVE 429 

62.  ENORMOUS    CONGENITAL    DEVELOPMENT    OF    THE    COLON              .      .  478 

65.  MAYDL'S   OPERATION   FOR   JEJUNOSTOMY      ...:..      524 

66.  ALBERT'S    OPERATION   FOR   JEJUNOSTOMY 625 


murphy's   METAL   BUTTON 256 

HEINEKE -MIKULICZ  OPERATION    OF   PYLOROPLASTY        .  .  .      266 


67. 
68. 
69. 


METHODS      OF        PERFORMING       ENTERO  -  ANASTOMOSIS        AFTER 

ENTERECTOMY         .........      527 


XXIV     SURGERY  OF  THE  ALIMENTARY  CANAL 

FIG.  PAGE 

70.  ^ 

„^    I    METHODS     OF     UNITING     BOWEL     ENDS     BY     SIMPLE     CIRCULAR 

^n'l  SUTURE 529 

73.    bishop's  suture 530 

74  ) 

■  [  abbe's  suture 531 

75.) 

76. 

\-  maunsell's  suture  .         .        .        .         .         .        .        .     533 

78. 

79.i 

80.  N 

81    I 

L  halsted's  suture .        .     ,     534 

82.  f 

83.) 

84.) 

f  senn  s    decalcified     bone     plates;     showing    mode     of 

„„"  [       threading  plates 536,  537 

87.     senn's  method  of  lateral  anastomosis 538 

88.] 

89. 1  PAUL'S  method  of  suture  with  decalcified  bone  tubes  .     589 

90.  J 

91.  ROBINSON'S   METHOD    OF   SUTURE   WITH   INDIARUBBER   TUBE       .      540 

92.  ROBSON'S    DECALCIFIED   BONE   BOBBIN 540 

93.] 

94.  I   murphy's   METHOD    OF   UNION   WITH   METAL   BUTTON     .  .      .      541 

95.  J 

96.  PAUL'S   METHOD    OF   PERFORMING   COLECTOMY     ....        548 
97.]     SHORT    CIRCUITING   WITH    OCCLUSION   OF   A   PORTION    OF    INTES- 

98.  [  TINE .  .      .      549 

100.] 

101.  I    RECTAL   BOUGIES 595 

102..) 

103.      CREDE'S   RECTAL   BOUGIE 598 

105.  roberts's  operation  for  prolapse  of  the  rectum     .  .     645 

106.  Mikulicz's  operation  for  prolapse  of  the  rectum        .     .     646 
107.\ 
108. 
109. 
110. 
111. 
112. 
113. 
114. 
115. 
116./ 
117.     OS  sacrum,  showing    the    amount    of    bone    removed    in 

operating  upon  the  rectum        ...         .         .     .     684 


diagrammatic    representations    of   malformations    of    THE 

anus   and    RECTUM 656 


THE    SUEGEEY 

OF    THE 

ALIMENTARY    CANAL 


PAET   I 

THE   CESOPIIAGUS 


CHAPTEE   I 

SURGICAL  ANATOMY  AND  PHYSIOLOGY 

Surgical  Anatomy. — The  relations  of  the  oesophagus  to 
surrounding  parts  are  of  considerable  importance.  Not 
only  are  important  parts  in  immediate  proximity  to  the  canal 
liable  to  be  affected  by  conditions  of  the  oesophagus  itself,  but 
diseases  arising  from  the  surrounding  parts  are  in  their  turn 
liable  to  produce  complications  of  which  the  oesophageal 
troubles  are  only  symptoms.  But,  apart  from  the  considera- 
tion of  disease,  these  same  surrounding  structures  render 
operations  upon  the  canal  of  special  difficulty,  or  at  least  in  need 
of  more  than  usual  care. 

Course  and  Extent. — The  cesophagus  extends  from  the 
cricoid  cartilage  above  to  about  opposite  the  body  of  the 
tenth  dorsal  vertebra  below ;  this  lower  point  corresponding 
posteriorly  with  the  apex  of  the  ninth  dorsal  spine,  and  an- 
teriorly with  the  junction  of  the  seventh  costal  cartilage  with 
the  sternum  on  the  left  side.  It  is  from  nine  to  ten  inches  in 
length,  and  takes  a  somewhat  sinuous  course.  At  first  situated 
in  the  median  line,  it  deviates  as  it  descends  to  the  left  side,  so 
that  at  the  root  of  the  neck  it  has  become  deflected  about  half 


2  THE    (ESOPHAGUS 

an  inch.  From  this  point  it  again  passes  to  the  middle  line, 
reaching  its  original  axis  opposite  the  body  of  the  fifth  dorsal 
vertebra.  It  again  deviates  slightly  to  the  left  as  it  passes 
through  its  opening  in  the  diaphragm.  This  latter  point  is 
approximately  opposite  the  spine  of  the  ninth  dorsal  vertebra. 
Besides  a  lateral  deviation,  the  cesophagus  is  curved  in  an 
antero-posterior  direction.  Following  the  course  of  the  spinal 
column,  it  is  first  directed  slightly  forward  by  the  convexity 
of  the  cervical  curve  ;  this,  however,  almost  at  once  gives  way 
to  a  concave  curve  as  it  sinks  into  the  root  of  the  neck  and  on 
into  the  thoracic  dorsal  curvature.  This  latter  curve,  according 
to  Morell  Mackenzie,  disappears  in  the  erect  posture.  As  the 
tube  enters  the  thorax  at  the  root  of  the  neck,  its  distance  from 
the  surface  in  the  adult  is  from  one  and  a  half  to  two  inches, 
the  variation  depending  upon  the  shortness  and  fatness  of  the 
part.  Before  leaving  the  thorax  it  is  directed  somewhat  for- 
wards to  enter  its  aperture  in  the  diaphragm.  Not  more  than 
half  an  inch  intervenes  between  the  diaphragm  and  its  junction 
with  the  stomach. 

Attaclmients. — The  oesophagus,  except  towards  its  termi- 
nation, is  only  loosely  attached  by  connective  tissue  to  the 
surrounding  parts.  The  curves  therefore  "easily  straighten  in 
the  passage  of  stout  bougies,  and  the  tube  is  permitted  to 
.accommodate  itself,  in  some  degree,  to  pressure  from  without. 
The  most  fixed  point  is  at  the  diaphragm. 

Relations. — Behind. — The  oesophagus  is  in  close  contact 
with  the  sjiinal  column  for  most  of  its  length.  As  it  leaves 
the  thorax  the  aorta  intervenes. 

In  front. — It  has  first  of  all  the  trachea  ;  lower  in  the  neck, 
where  it  deviates  to  the  left  side,  the  thyroid  gland  and  the 
thoracic  duct.  After  entering  the  thorax  it  is  crossed  by  the 
arch  of  the  aorta  and  the  left  bronchus ;  for  the  rest  of  its 
extent  it  is  covered  by  the  pericardium.  On  each  gide  in  the 
neck  it  has  the  carotid  artery,  the  left  being  in  closer  contact 
than  the  right.  In  the  thorax  the  aorta,  after  crossing  the  oeso- 
phagus at  its  upper  part,  lies  to  the  left,  and  the  vena  azygos 
major  to  the  right.  It  is  also  covered  laterally  by  the  pleurse. 
In  the  neck  the  recurrent  laryngeal  nerves  ascend  between  it 
and  the  trachea  ;  while  in  the  thorax  the  pneumogastric  nerves 
descend  in  close  contact  with  it. 


SUllOTCAL     ANATOMY  3 

Calibre. — The  oesophagGal  canal  is  the  narrowest  of  any 
portion  of  the  alimentary  tract  ;  and  narrower  in  itself  at  the 
commencement  opposite  the  cricoid  cartilage  and  at  the  exit 
through  the  diaphragm.  It  is  also  constricted  somewhat  at 
the  point  where  it  is  crossed  by  the  left  bronchus.  Mouton, 
by  ol)taining  a  cast  of  the  canal  with  plaster  of  Paris,  found 
that  at  these  three  constricted  parts  the  internal  diameter 
measured  a  little  above  half  an  inch,  while  at  other  parts  it 
was  about  three-quarters  of  an  inch.  By  forcible  dilatation  it 
was  found  possible  to  increase  the  diameter  of  the  cricoid  and 
bronchial  constrictions  to  about  three-quarters  of  an  inch,  the 
diaphragmatic  to  nearly  an  inch,  and  the  other  parts  to  about 
an  inch  and  a  half.  It  must,  however,  be  remembered  that 
these  are  post-mortem  experiments  and  cannot  well  be  accej)ted 
as  examples  of  what  amount  of  dilatation  can  take  place  during 
life.  They  are  of  value,  however,  in  giving  information  regard- 
ing the  relative  diameter  of  different  parts  of  the  canal.  Mac- 
kenzie, experimenting  in  the  same  way,  showed  that  the  antero- 
posterior diameter  is  considerably  less  than  the  transverse. 

Structure. — The  oesophagus  resembles  other  portions  of 
the  alimentary  tract  in  being  composed  of  muscular,  fibrous, 
and  mucous  coats.  In  comparison  with  other  regions  its 
muscular  coat  is  very  thick  ;  the  fibrous  coat  is  also  thick, 
although  loose  in  texture,  and  the  mucous  coat,  lined  with 
several  layers  of  squamous  epithelium,  is  similarly  thick  and 
firm.  This  last  coat  is  thrown  into  numerous  longitudinal 
folds  when  the  canal  is  at  rest,  that  is,  when  not  distended. 
Numerous  mucous  glands  exist  in  the  submucous  or  fibrous 
layer.  ■  The  arteries  are  disposed  mostly  longitudinally,  and 
are  more  abundant  at  the  upper  than  the  lower  part,  hence  the 
paler  appearance  of  the  canal  below.  The  veins  form  plexuses 
in  the  submucous  tissue  and  in  the  peri -oesophageal  tissue. 
Numerous  anastomoses  are  formed  between  these  plexuses 
and  the  veins  of  the  portal  system  and  the  vena  cava  (C.  A. 
Blume).'  The  lymphatics  of  the  thoracic  part  pass  into  the 
posterior  mediastinal  glands,  while  those  of  the  cervical  por- 
tion go  to  the  deep  glands  beside  the  carotid  sheath.  The 
nerve  supply  is  through  the  pneumogastric. 

'  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  iv.  G — 36. 

li  2 


4  THE    (ESOPHAGUS 

Physiology. — The  functions  of  the  oesophagus  are  essenti- 
ally those  connected  with  the  rapid  transmission  of  the  food 
from  the  pharynx  to  the  stomach.  The  muscular  coat  is 
specially  thick  for  this  purpose,  and  the  numerous  glands 
a'imit  of  an  abundant  viscid  secretion  for  lubrication.  The 
constant  friction  to  which  the  internal  surface  is  exposed  is 
met  by  the  extra  thick  layer  of  squamous  epithelium.  With 
regard  to  the  rate  of  progress  in  the  canal,  Ogston  found  that 
the  time  required  for  the  passage  of  food  from  the  mouth  to  the 
stomach  was  about  four  seconds.  To  determine  this,  the  finger 
of  one  hand  is  placed  on  the  pomum  Adami,  the  other  hand 
holds  the  watch,  and  the  ear  is  placed  '  behind  the  left  thorax, 
three  inches  below  the  angle  of  the  scapula.'  When  some  fluid 
is  swallowed,  the  time  is  reckoned  from  the  moment  the  pomwii 
is  felt  to  rise,  till  a  '  distinct  amphoric  gurgle  or  amphoric  rush- 
ing sound '  is  heard,  indicating  the  passage  of  the  fluid  into 
the  stomach.^ 


CHAPTER   II 

INJURIES.       INTERNAL    AND    EXTERNAL    INJURY.       RUPTURE 

Injuries  to  the  oesophagus  may  arise  from  causes  either  inside 
or  outside  the  canal.  Those  inflicted  from  within  are  the  more 
frequent,  and  as  a  rule  the  less  severe.  On  the  other  hand,  in 
the  case  of  external  injuries,  the  depth  of  the  gullet  from  the 
surface,  and  the  important  structures  surrounding  it,  prevent 
generally  any  material  damage  to  the  former,  without  far  more 
serious  concomitant  injury  to  the  latter.  Injuries  inflicted 
therefore  from  without  may  be  looked  upon  more  as  surgical 
curiosities,  for  either  life  has  already  become  extinct  before  the 
surgeon  sees  the  case,  or  the  injury  is  so  hopelessly  irreparable 
as  to  be  beyond  treatment.  Cases,  however,  are  occasionally 
met  with  where  surgical  measures  have  succeeded.  These  will 
be  referred  to  later  on. 

Internal  injuries. — These  may  be  of  the  nature  of  incised, 
punctured,  or  lacerated  wounds,  and  burns  or  scalds.  Any 
part  of  the  wall  of  the  canal  may  be  injured.     The  narrower 

'  Medical  Chronicle,  1886,  vol.  v.  p.  280. 


INJURIES  5 

parts  opposite  the  cricoid  cartilage  and  the  diaphragm  are 
those  which  most  frequently  suffer.  The  injury  may  be  of 
any  degree,  from  a  single  scratch  or  abrasion  to  a  perforation. 
In  the  latter  case  neighbouring  important  structures  may  also 
be  injured. 

The  agencies  whereby  these  various  wounds  are  produced 
are  extremely  numerous.  Exclusive  of  such  materials  as 
cause  burns  or  scalds,  objects  of  all  sizes  and  descriptions 
have  been  swallowed,  intentionally  or  accidentally  ;  swords, 
foils,  and  other  sharp-edged  weapons  have  been  inserted  for 
juggling  or  suicidal  purposes.  The  nature  of  the  wound  pro- 
duced will  largely  depend  upon  the  shape  and  consistency  of 
the  body  introduced.  In  the  case  of  sharp-edged  or  sharp- 
pointed  weapons  the  wound  will  be  an  incised  or  punctured 
one.  In  that  of  metallic  substances,  or  irregular-shaped 
splinters  of  bone,  broken  bits  of  china,  and  other  suchlike 
hard  brittle  jagged  bodies,  the  injury  will  be  mostly  of  a 
lacerated  character. 

Symptoms. — These  will  depend  largely  upon  the  nature  of 
the  lesion.  A  mere  abrasion  or  scratch  will  give  rise  to  a 
feeling  of  soreness  in  the  process  of  deglutition,  and  frequently 
create  the  impression  that  a  foreign  body  has  become  impacted 
at  the  spot  where  pain  is  complained  of.  A  deeper  injury  will 
cause  some  bleeding,  and  this  may  give  rise  to  cough  with 
bloody  expectoration  or  vomiting  of  blood  that  has  passed  into 
the  stomach.  A  punctured  or  perforating  wound  will  give  rise 
to  symptoms  depending  mostly  upon  the  organ  or  structure 
simultaneously  injured.  Thus  involvement  of  a  large  blood 
vessel  will  produce  rapid  symptoms  of  hsemorrhage ;  an  opening 
into  the  trachea  or  left  bronchus,  to  cough  and  expectoration  of 
blood,  mucus,  and  food ;  perforation  of  the  pleura  or  pericar- 
dium, to  considerable  collapse.  To  these  immediate  symptoms 
may  be  added  great  thirst,  pain,  and  dysphagia.  Later,  sym- 
ptoms will  be  mostly  of  an  inflammatory  character,  due  to  the 
communication  opened  up  between  the  oesophagus  and  the 
neighbouring  parts.  Thus  an  abscess  may  form  from  simple 
penetration  of  the  cellular  tissue  in  the  neck  or  mediastinum  ; 
pleurisy,  empyema,  and  pneumothorax  from  opening  of  the 
pleural  cavity ;  and  similarly  pericarditis  from  perforation 
of  the  pericardial  cavity.      Pneumonia  may  arise  either  as 


6  THE    (ESOrilAGUS 

secondary  to  inflammation  of  the  pleura  or  as  a  result  of 
injury  to  the  air  passages  themselves. 

Diagnosis. — Internal  injuries  to  the  oesophagus  will  be,  in 
the  first  place,  mostly  recognised  by  the  previous  history  of 
the  case  ;  and  the  nature  of  the  lesion  will  also  often  be  arrived 
at  by  the  kind  of  body  producing  it.  In  the  second  place,  the 
symptoms  associated  with  the  act  of  deglutition,  such  as 
dysphagia,  localise  pain,  and  regurgitation  or  vomiting  of 
blood  will  leave  little  doubt  regarding  the  region  injured. 

Prognosis. — Judging  from  the  way  in  which  wounds  pro- 
duced by  the  surgeon  heal,  the  oesophagus  is  in  no  way  excep- 
tional in  its  recuperative  powers.  Hence  when  the  injury  has 
not  been  of  a  grave  nature  and  the  exciting  cause  has  been 
removed,  a  good  result  may  be  expected.  Should,  however, 
the  lesion  have  been  produced  by  a  foreign  body  which  has 
not  been  passed  on  into  the  stomach,  nor  extracted,  other 
results  must  be  expected.  These  will  be  treated  of  later.  In 
cases  of  severer  injuries,  where  the  immediate  symptoms  point 
to  the  involvement  of  other  structures  and  parts,  the  pro- 
gnosis will  have  to  be  a  guarded  one.  If  the  case  be  not  rapidly 
fatal,  there  are  all  the  possible  secondary  complications  arising 
from  septic  causes.  The  final  issue  of  the  case  then  turns 
upon  these  sequelse  and  their  treatment. 

Case  I. — A  diffuse  perioesophageal  abscess  in  a  '  sword  sivalloiuer.'' 
E.  S.,  set.  30,  was  admitted  into  St.  Saviour's  Infirmary,  Walworth, 
January  17,  1885.  Two  days  before  admission  he  had  been  performing 
at  a  pubUc-house,  swallowing  a  sword.  The  feat  on  this  occasion  hurt 
him  more  than  usual,  and  he  spat  a  little  blood  immediately  afterwards. 
He  then  felt  great  pain  about  the  throat  and  oesophagus,  much  increased 
on  swallowing.  On  admission  the  neck  was  swollen  and  tender,  breathing 
shallow  and  hurried,  and  he  continually  spat  up  a  little  glairy  mucus  not 
stained  with  blood.  He  gradually  became  worse,  and  died  suddenly  on 
January  20.  The  autopsy  showed  a  diffuse  abscess  extending  along  the 
pharynx  and  oesophagus.  The  mucous  membrane  of  the  latter  was  thick- 
ened, quite  smooth,  and  white  in  colour.  The  outermost  coat  and  sur- 
rounding tissue  were  infiltrated  with  pus.  The  left  vagus  was  seen  running 
through  the  abscess  cavity  at  the  lower  part.  There  was  no  evidence  of 
any  perforation  or  wound,  and  only  a  slight  excoriation  at  the  upper  and 
posterior  part.  The  condition  of  the  mucous  membrane  showed  a  chronic 
thickening  from  the  continual  irritation  of  the  part  by  the  passage  of  the 
hard  solid  substances.  The  man  had  been  a  sword  swallower  and  con- 
jurer for  years.  (Gross,  '  Trans.  Path.  Soc.  Lond.'  1885,  vol.  xxxvi. 
p.  188.) 


INJURIES  7 

In  the  case  of  burns,  the  gravity  of  the  hnmediate  symptoms 
is  not  connected  with  injury  to  the  oesophagus,  hut  rather  with 
affection  of  parts  about  the  larynx  and  pharynx.  Apart  from 
a  knowledge  of  the  nature  of  the  fluid  or  material  swallowed, 
it  may  be  fairly  stated  that  as  regards  the  cesophagus  the 
prognosis  is  directly  proportionate  to  the  severity  of  the 
symptoms  connected  with  the  injury  to  the  larynx  and  pharynx. 
If  there  is  much  mischief  here,  then  it  is  only  too  likely  that 
the  oesophagus  will  have  suffered  badly ;  and  if  this  be  the 
case,  sloughing  or  ulceration  may  result,  with  the  subsequent 
formation  of  stricture. 

Treatment— The  essential  basis  of  all  treatment  is  rest. 
The  surface  of  the  mucous  membrane  must  be  protected  from 
friction,  and  the  muscles  must  be  prevented  from  action.  This 
is  best  effected  by  giving  no  food  by  the  mouth,  but  feeding 
the  patient  with  nutrient  enemata.'  Thirst  may  be  appeased 
by  a  little  ice  given  by  the  mouth ;  and  should  much  pain 
exist  it  must  be  allayed  by  anodynes  given  subcutaneously  or 
per  rectum.  A  week  or  two  should  be  allowed  to  elapse  before 
food  is  given  by  the  mouth,  and  then  fluids  only  should  be 
first  administered.  Special  symptoms  arising  later  will  call 
for  treatment  according  to  the  complications  they  indicate. 

In  the  case  of  injuries  produced  by  swallowing  concentrated 
acids  or  caustic  alkaline  solutions,  resort  should  be  had  as 
soon  as  possible  to  the  imbibition  of  fluids  or  other  substances 
which  might  either  neutralise  the  agent  swallowed  or  dilute 
its  concentration.  Thus  without  going  into,  to  any  extent, 
the  treatment  of  those  cases  of  poisoning  which  will  be  found 
more  fully  dealt  with  in  books  on  general  or  forensic  medicine, 
it  may  be  briefly  stated  that  the  immediate  administration  of 
large  quantities  of  water  and  its  rapid  removal  by  the  stomach 
pump  will  often  prove  the  best  means  at  hand  to  adopt. 

External  injuries. — Apart  from  operations  on  the  cesophagus 
and  its  accidental  injury  in  tracheotomy,  injuries  inflicted  from 
without,  and  involving  the  gullet  alone,  are  comparatively  rare. 
Such,  however,  have  occurred  from  bullets,  sword,  foil  or 
dagger  thrusts  inflicted  in  war,  or  with  homicidal  intent. 
Far  more  common  is  it  for  such  injuries  to  be  associated  with 
serious  mischief  to  other  and  neighbouring  parts. 

'  See  Chapter  LXXXIV. 


8  THE    (ESOPHAGUS 

The  nature  of  the  wound  may  be  incised,  punctured,  or 
lacerated,  and  may  pass  simply  into  the  canal  or  entirely 
through  it.  In  cases  of  strangulation  or  garroting  the  oeso- 
phagus may  be  contused. 

Symptoms. — Many  of  these  will  be  those  already  given  in 
the  case  of  internal  injuries :  there  will  be  pain,  dysphagia, 
and  cough  ;  possibly  great  thirst  and  troublesome  hiccough, 
and  symptoms  arising  from  general  disturbance.  In  addition 
there  are  those  connected  with  the  external  wound,  such  as 
the  escape  of  mucus  or  ingesta.  To  what  extent  these  latter 
symptoms  may  manifest  themselves  will  largely  depend  on  the 
size  and  nature  of  the  opening. 

Diagnosis. — Where  the  symptoms  are  marked,  little  diffi- 
culty will  be  experienced  in  deciding  whether  or  not  the  gullet 
has  been  injured.  Care  must,  however,  be  taken  not  to  con- 
clude that  the  escape  of  food  from  the  wound  is  necessarily 
an  indication  of  perforation  of  the  gullet.  A  simple  opening 
into  the  trachea  may  prove  a  source  of  exit  for  fluids  which 
have  trickled  into  the  larynx  from  some  defective  action  of 
the  glottis.  The  direction  of  the  wound,  and  its  depth,  will 
also  assist  in  localising  the  injury.  With  regard  to  the  nature 
of  the  wound,  this  may  be  approximately  gathered  from  the 
character  of  the  agent  causing  it. 

Prognosis. — With  the  exception  of  uncomplicated  incised 
wounds,  all  other  injuries  must  be  looked  upon  as  of  consider- 
able gravity.  A  lacerated  wound,  such  as  that  produced  by  a 
bullet,  may  lead  on  the  one  hand  to  a  stricture,  or  on  the 
other  to  a  fistulous  communication  with  the  skin  surface. 
Various  septic  conditions  may  arise  of  more  or  less  serious 
character.  In  cases  of  severe  haemorrhage  where  death  has 
not  occurred  immediately,  the  great  loss  of  blood  may 
seriously  affect  the  recuperative  powers  of  the  patient.  That 
even  comparatively  severe  gunshot  injuries  may  sometimes 
recover,  Solis-Cohen  has  pointed  out,  quoting  from  the  medical 
and  surgical  history  of  the  war  of  the  Eebellion,  twelve  cases, 
where  recovery  occurred  in  as  many  as  six.  In  cases  of  almost 
complete  severance  of  the  canal  and  serious  interference  with 
its  continuity,  death  may  subsequently  ensue  from  starvation, 
it  being  found  impossible  to  supply  sufficient  nourishment. 
In  cases  of  injury  to  the  oesophagus  in  the  thorax,  the  pro- 


iXJLIUE.S  y 

gnosis  is  necessarily  bad.  If  not  almost  immediately  fatal, 
there  are  all  the  secondary  complications  of  the  same  nature  as 
those  already  given  in  the  case  of  internal  injuries. 

Treatment. — In  treating  wounds  of  the  cesophagus  inflicted 
from  without,  we  have  to  devote  as  much  attention  to  the 
patient  generally  as  to  the  wound  in  particular.  In  other 
words,  we  have  to  keep  up  the  patient's  strength  without 
interfering  deleteriously  with  the  wound.  As  regards  the 
wound,  the  first  question  which  usually  presents  itself  is 
whether  an  endeavour  should  or  should  not  be  made  to  close 
the  opening  in  the  oesophagus.  This  can  only  be  answered  by  a 
careful  consideration  of  the  nature  of  the  wound  itself.  In 
cases  of  clean-cut,  incised,  or  punctured  wounds  an  endeavour 
may  safely  be  made  to  completely  occlude  the  aperture.  This 
may  be  done  either  by  a  continuous  or  interrupted  suture  of 
sterilised  silk  or  gut.  And,  further,  where  the  wound  is  recent 
and  it  is  believed  that  it  is  or  can  be  rendered  aseptic,  the 
external  wound  may  also  be  closed.  In  every  case  of  doubt, 
however,  on  this  latter  point,  and  where  also  the  closure  of  the 
oesophageal  wound  leaves  doubt  as  to  its  efficiency,  the  external 
or  surface  wound  should,  if  not  left  wholly  open,  be  very 
thoroughly  drained  by  tubes.  Lacerated  wounds  of  the  gullet 
admit,  as  a  rule,  of  but  little  treatment,  and  may  even  some- 
times have  to  serve  as  apertures  for  the  admission  of  a  feeding 
tube.  Cases  of  this  kind  are  apt  to  leave  troublesome  external 
fistul8e,and  treatment  subsequently  resolves  itself  into  measures 
for  the  occlusion  of  these.  For  this  purpose  the  usual  means 
for  such  conditions  may  be  adopted,  as  the  cautery,  caustic,  &c. 

In  any  kind  of  wound  of  the  oesophagus,  and  especially  if 
it  be  associated  with  wound  of  the  trachea,  the  head  should  be 
secured  by  bandages  to  the  trunk,  so  that  as  little  movement  as 
possible  of  the  neck  is  permitted.  Any  complications  which  sub- 
sequently arise  must  be  treated  on  general  surgical  principles. 

As  regards  the  patient,  our  chief  consideration  concerns 
the  ef&cient  administration  of  nourishment.  Eectal  alimen- 
tation should  in  all  cases  be  adopted,  and  if  this  can  be  success- 
fully carried  on  for  over  a  week,  the  best  opportunity  is 
afforded  for  the  wound  to  heal.  Cases,  however,  will  occur 
where  such  means  of  nutrition  will  prove  inefficient  and 
something  must  be  conveyed  to  the  stomach.    The  best  method, 


10  THE    CESOPIIAGUS 

if  possible,  is  the  natural  one,  the  administration  of  nutrient 
fluids  in  teaspoonful  doses  by  the  mouth.  If  this  cannot  be 
done,  then  a  stomach  tube  must  be  passed  by  the  mouth  if 
possible,  or,  if  that  be  not  possible,  by  the  wound.  The  chief 
objection  to  the  use  of  the  tube  is  not  only  the  injury  it  may 
inflict  upon  the  wound  in  its  passage,  but  the  likelihood  of  its 
inducing  retching  or  vomiting,  results  which  would  them- 
selves act  injuriously  in  unduly  stretching  the  parts.  It  need 
hardly  be  said  that  in  cases  which  have  done  well  under  rectal 
alimentation  the  return  to  feeding  by  the  mouth  should  be 
both  gradual  and  cautious.  Bland  unirritatmg  nutrient 
fluids  should  be  given  first  in  small  quantities — a  teaspoonful 
at  a  time.  Only  after  the  lapse  of  a  fortnight  or  three  weeks 
should  solid  food  be  attempted,  and  even  then  only  foods  of  a 
soft  consistency  and  that  have  been  well  masticated.  The 
sole  endeavour  being  not  to  overdistend  the  wounded  region, 
precautions  should  be  taken  accordingly.  In  cases  of  great 
thirst,  the  fluid  should  be  administered  by  enemata,  and,  if 
necessary,  ice  may  be  given  to  suck.  Pain  may  be  allayed  by 
the  usual  anodyne  measures. 

Rupture  of  the  oesophagus. — Judging  from  the  compara- 
tively few  recorded  cases,  rupture  of  the  oesophagus  must  be  a 
very  rare  accident,  and  still  rarer  are  those  cases  in  which  the 
rupture  has  occurred  in  a  practically  healthy  organ.  Many  of 
the  earlier  cases  recorded,  as  shown  by  Fitz,*  are  too  doubtful 
to  be  accepted  as  illustrations  of  the  accident,  and  many  also 
recorded  as  ruptures  are  the  result  of  post-mortem  softening 
of  the  walls. 

The  nature  of  this  rare  accident  wiU  be  best  illustrated  by 
the  brief  record  of  a  few  cases. 

Case  II. — Bujjture  produced  by  vomiting. 
A  man,  aged  47  years,  had  for  some  months  suffered  from  troublesome 
dyspeptic  symptoms,  giving  rise  to  frequent  attacks  of  vomiting,  and  sug- 
gesting the  possibility  of  malignant  obstruction  at  the  pylorus.  After 
svi^allowing  some  milk  arrowroot,  he  vomited,  and  was  seized  with  sudden 
and  intense  pain  in  the  lower  part  of  the  left  side  of  the  chest.  He  thought 
that  something  had  burst  in  his  stomach.  Marked  collapse  rapidly  en- 
sued, with  rapid  and  weak  pulse,  liurried  respiration,  and  some  difficulty 
in  breathing  ;  temperature  subnormal.     A  few  hours  later,  subcutaneous 

'  Fitz,  Am.  J.  Med.  Sciences,  1877,  N.S.  vol.  Ixxiii.  p.  17. 


KUITUIJE  II 

emphysema  of  the  neck,  cheeks,  and  upper  part  of  the  chest  developed. 
On  examining  the  chest  the  area  of  cardiac  duhiess  was  observed  to  have 
disappeared,  and  this  region  and  the  upper  part  of  the  left  lung  were  found 
to  be  hyper-resonant  on  percussion.  Eespiratory  sounds  were  feeble, 
though  present  over  the  left  lung  in  front,  and  exaggerated  o^s-er  the  right 
hing.  The  emphysema  gradually  increased,  the  pulse  became  weaker,  and 
death  ensued  thirteen  and  a  half  hours  after  the  onset  of  the  acute  sym- 
ptoms. 

Post  mortem. — Extensive  emphysema  existed  everywhere,  reaching 
as  low  as  the  groins.  Each  pleural  cavity  contained  about  a  pint  of  dark 
grumous  fluid  having  the  odour  and  appearance  of  the  contents  of  the 
stomach.  On  examining  the  oesophagus  a  longitudinal  rent  an  inch  and 
a  half  long  was  found  in  its  walls  just  above  the  diaphragm.  The  edges 
of  the  rent  were  sharply  defined  and  gave  no  evidence  of  induration  or  of 
a  fore-existing  ulcerative  or  degenerative  process.  They  bore  no  indica- 
tion of  post-mortem  softening.  No  constriction  or  dilatation  of  the  oeso- 
phagus existed,  and  no  pouch  or  thinning  of  its  walls  could  be  detected. 
The  stomach  was  somewhat  dilated.  At  the  pyloric  orifice  a  small  nodule 
of  carcinoma  was  found,  and  the  whole  circumference  of  the  orifice  was 
more  or  less  thickened  and  indurated  by  the  disease.  (C.  E.  Harrison, 
'  Lancet,'  1893,  vol.  i.  p.  784.) 

Case  III. — Rupture  of  oesophagus  during  a  violent  endeavour  to  dislodge 
an  imj^acted  mass  of  food :  death  from  exhaustion  in  seven  and 
a  half  days. 

Mr.  H.,  31  years  of  age,  suffered  from  debility  due  to  long  continued 
abuse  of  alcoholic  stimulants.  He  suffered  at  times  from  attacks  of 
gastritis,  when  he  would  frequently  vomit  blood.  He  never  complained 
of  pain  or  difficulty  in  swallowing.  "While  at  supper  on  January  26,  1876, 
he  suddenly  became  partially  choked  by  some  article  of  food  lodging 
somewhere  in  the  throat.  After  an  hour  of  great  discomfort  and  intense 
anxiety,  he  succeeded,  by  a  concentration  of  his  entire  muscular  energy, 
in  ejecting  the  obstructing  fragment.  He  sank  back  upon  the  sofa 
exhausted,  and  almost  immediately  ejected  a  moderate  quantity  of 
clotted  and  liquid  blood.  After  being  put  to  bed  he  complained  of  thirst ; 
fluids  were  swallowed  easily  and  without  discomfort.  He  vomited  once, 
an  hour  after  the  food  was  ejected,  and  the  vomit  contained  no  blood. 
Emphysema  of  the  neck  was  marked  and  continued  to  increase.  On  the 
following  day  the  emphysema  had  further  extended  ;  thirst  was  constant, 
and  vomiting  frequent,  blood  being  occasionally  present  in  the  ejecta. 
Swallowing  was  without  difficulty  and  without  pain.  Weakness  and 
prostration  increased,  and  on  February  3— seven  and  a  half  days  after  the 
onset  of  his  troubles — he  died.  At  the  autopsy  a  rent  in  the  oesophagus, 
was  found,  two  inches  in  length,  and  extending  through  all  its  coats,  situ- 
ated in  front  and  to  the  right,  at  and  below  the  bifurcation  of  the  trachea. 
No  evidence  of  disease  of  any  kind  was  found  in  the  region  of  the  rupture. 
(Fitz,  '  American  Journal  of  the  Medical  Sciences,'  1877,  N.S.  vol.  Ixxiii, 
p.  18.) 


12  THE    (ESOPHAGUS 

These  two  cases  illustrate  rupture  of  an  apparently  healthy 
oesophagus.  The  following  lesion  occurred  in  a  patient  where 
there  was  reason  to  believe  from  the  post-mortem  appearances 
that  the  oesophagus  had  been  weakened  by  previous  ulceration. 

Case  IV. — Rupture  of  the  oesophagus  during  vomiting  after  a  heavy 
meal :  death  in  seven  hours. 

The  patient  was  a  gentleman  aged  53  years.  He  had  been  dyspeptic 
for  several  years,  and  occasionally  vomited  after  food.  On  the  day  of  his 
death  he  appeared  unusually  v^^ell  and  went  out  on  a  pleasure  excursion. 
He  returned  to  his  dinner  in  the  afternoon  and  ate  heavily  of  a  rump 
steak.  About  two  hours  after  his  dinner  he  complained  of  faintness  and 
left  the  room.  Soon  afterwards  he  was  heard  retching  in  the  watercloset, 
and  then  to  utter  a  shriek.  He  returned  to  the  dining-roora  pale  as  death, 
threw  himself  on  to  the  sofa,  coraplaining  of  great  pain  in  his  left  side  and 
shoulder.  When  seen  by  his  doctor  he  was  in  a  cold  sweat,  breathing 
quick  and  short,  his  pulse  122,  and  his  face  expressive  of  agony.  He 
kept  his  left  hand  firmly  pressed  upon  his  left  side,  where  he  complained 
of  severe  pains  extending  to  the  point  of  the  left  shoulder.  He  died  seven 
hours  after  the  sickness.  At  the  post  mortem  a  slit  was  found  in  the 
oesophagus  a  quarter  of  an  inch  in  length,  immediately  above  the  dia- 
phragm. The  left  i)leural  cavity  contained  about  a  pint  of  undigested  food, 
amongst  which  was  a  piece  of  gristle  of  beef,  an  inch  and  a  half  long  and  an 
inch  broad,  which  was  supposed  to  be  the  agent  which  had  caused  the  rup- 
ture.    (William  Adams, '  Trans.  Path.  Soc.  Lond.'  1878,  vol.  xxix.  p.  113.) 

The  following  two  cases  illustrate  a  form  of  rupture  rather 
of  pathological  than  surgical  interest.  In  these  cases  it  will 
be  seen  that  the  rupture  has  indirectly  occurred  as  the  result 
of  gastric  solution  of  the  walls  of  the  oesophagus,  the  latter 
process  occurring  from  enfeeblement  of  the  parts  just  prior  to 
death. 

Case  V. — Rupture  of  the  cesophagus  :  softening  of  the  walls  by  gastric 
solution  just  pirior  to  death. 

A  child  aged  4  months  was  admitted  into  University  College  Hospital, 
under  the  care  of  Mr.  Godlee,  with  the  symptoms  of  strangulated  hernia. 
He  was  relieved,  but  some  days  later  took  erysipelas,  and  finally  septic 
peritonitis,  of  which  he  died.  Before  death  the  child  was  in  a  very 
exhaiisted  condition.  He  vomited  frequently  on  the  last  night  but  one 
before  death,  but  on  the  last  night  not  at  all.  Eather  more  than  two 
hours  before  death  sudden  difficulty  in  breathing  appeared,  and  continued 
for  an  hour.  Inspiration  was  accompanied  by  a  whifiEing  noise.  After 
the  dyspnoea  had  passed  off,  he  took  food  in  very  small  quantities  and 
without  difficulty  imtil  twenty-five  minutes  before  death.  At  the  post 
mortem,  at  a  point  midway  between  the  bifurcation  of  the  trachea  and  the 


openinjj:  in  the  diaphragm,  a  small  hole  was  found  in  tlie  a-sopliagxis  on 
the  right  side.  Both  inside  and  outside  the  gullet  a  little  blood-stained 
fluid  and  clots  were  fomid,  but  no  milk  in  the  latter  situation.  The  margin 
of  the  opening,  which  was  circular,  was  smooth  aboA^e  and  quite  thin  below, 
and  in  general  suggested  gastric  solution  of  the  part.  (Stanley  Boj'd, 
'  Trans.  Path.  Soc.  Lond.'  1882,  vol.  xxxiii.  p.  123.) 

Case  VI. — RuiHure  of  the  ceso2)hagus  where  the  tvalls  had  become  softened 
by  gastric  solution. 
E.  B.,  a  young  woman  aged  18,  was  admitted  into  University  College 
Hospital  under  the  care  of  Mr.  Heath.  She  was  in  a  state  of  great  collapse, 
and  died  in  ten  or  twelve  hours.  She  was  vomiting  on  admission,  and 
every  kind  of  stimulant  or  food  given  by  the  mouth  returned  unaltered 
before  it  could  have  reached  the  stomach.  She  complained  of  pain  about 
the  lower  end  of  the  sternum,  but  it  was  not  severe.  There  was  no  dys- 
pnoea and  no  subcutaneous  emphysema  noticed.  The  patient  passed  water 
in  the  bed.  At  the  post-mortem  examination  two  or  three  ounces  of 
bloody  fluid  which  contained  no  food  were  found  in  the  left  pleura  and 
seemed  to  have  come  from  a  rent  in  the  left  side  of  the  oesophagus.  The 
aperture  was  longitudinal,  about  two  inches  in  length,  and  situated  imme- 
diately above  the  cardia.  The  slitlike  character  of  the  aperture,  and  the 
existence  of  an  uneven  furrow  between  the  longitudinal  rugae  and  parallel 
with  it,  led  to  the  belief  that  gastric  solution  had  taken  place  at  the  seat 
of  rupture.  (Stanley  Boyd,  '  Trans.  Path.  Soc.  Lond.'  1882,  vol.  xxxiii. 
p.  125.) 

In  this  case  it  was  subsequently  ascertained  that  the 
patient  was  suffering  from  Addison's  disease,  and  that  tlie 
vomiting  with  which  she  was  troubled  on  admission  was  part 
of  the  symptoms  of  that  disease.  It  had,  however,  proved  the 
immediate  cause  of  death,  by  leading  to  rupture  of  the  oeso- 
phagus. 

The  cases  thus  quoted  will  serve  to  illustrate  the  various 
forms  in  which  rupture  may  occur.  They  may  be  divided 
into  three  classes  : 

1.  Spontaneous  rupture  in  a  practically  healthy  canal. 

2.  Spontaneous  rupture  in  a  canal  weakened  either  by 
ulceration  or  cicatrisation. 

3.  Spontaneous  rupture  in  a  canal  which  has  undergone  in 
parts  gastric  solution. 

(1)  In  the  first  class,  that  of  rupture  of  a  healthy  canal, 
the  rupture  can  only  occur  as  the  result  of  some  violent  effort 
to  expel  an  impacted  body.  The  patient  makes  every  possible 
eifort  to  eject  the  body.  The  diaphragm  is  first  fixed  after  an 
inspiration,  and  the  lungs  thus  distended  are  made  to  e]idure 


U  THE    (ESOPHAGUS 

an  overstrain  in  the  endeavour  to  liavrk  up  the  substance.  As 
a  result  of  this  strain,  some  rupture  of  the  air  vesicles  may 
take  place  with  consequent  emphysema.  Rupture  also  of  small 
blood  vessels  may  result,  with  expectoration  of  blood.  Coupled 
with  this  is  the  intense  anxiety  of  the  patient,  accompanied 
later  with  considerable  exhaustion.  Should  the  impacting 
body  be  expelled,  as  it  may  be  by  the  final  extraordinary  effort 
which  at  the  same  'time  ruptures  the  oesophagus,  it  will  be 
ejected  with  great  force.  The  patient  may  at  this  moment 
become  conscious  of  something  having  given  way,  and  may 
or  may  not  be  attacked  with  sudden  pain.  The  symptoms 
for  some  time  will  be  those  connected  with  the  excessive  exer- 
tion, and  the  great  exhaustion  thus  entailed  may  mask  any 
immediate  indication  of  rupture.  Later,  however,  symptoms 
will  show  themselves  which,  while  giving  no  direct  evidence 
of  the  lesion,  will  excite  suspicion  that  there  is  more  in  the 
case  than  can  be  accounted  for  by  the  efforts  at  expulsion. 
The  rupture  will  admit  of  the  escape  of  material — not  neces- 
sarily in  any  quantity — into  the  surrounding  parts.  The  result 
will  be  the  setting  up  of  some  septic  action,  and  according  to 
the  seat  of  this  action  will  be  the  symptoms  which  will  sub- 
sequently arise.  There  may  or  may  not  be  vomiting,  and 
there  may  or  may  not  be  difficulty  in  swallowing. 

It  will  thus  be  seen  that  the  symptoms  of  rupture  of  the 
oesophagus  in  this  class,  as  judged  from  the  comparatively  few 
cases  recorded,  are  very  variable  and  inconstant. 

Treatment. — TMien  it  has  been  possible  to  make  a  diagnosis, 
or  when  suspicions  lie  in  the  direction  of  rupture,  the  treat- 
ment will  be  as  already  given  under  the  head  of  Internal 
Injuries  ;  and  such  complications  as  may  subsequently  arise 
will  be  treated  on  general  surgical  principles. 

(2)  In  the  second  class  of  cases,  where  rupture  has  occurred 
in  a  previously  weakened  cesophagus,  the  cause  is  of  a  much 
less  violent  nature  and  the  symptoms  somewhat  more  charac- 
teristic. In  this  class  probably  come  most  of  the  cases  usually 
recorded  as  rupture  of  the  oesophagus.  The  patient  may  for 
some  time  previously  have  had  symptoms  indicating,  if  not 
definitely,  some  stomachic  or  oesophageal  trouble,  as,  for  in- 
stance, in  a  case  reported  by  Morley,'  where  the  man,  who  was 

'  Solis-Cohen,  Amuial  of  the  Universal  Medical  Sciences,  1892,  vol.  iv.  F — 34. 


IIUPTUKE  15 

a  great  drinker,  had  suffered  from  several  attacks  of  chronic 
gastritis.  On  the  other  hand  the  patient  may  have  appeared 
to  enjoy  good  health. 

The  accident,  it  appears,  occurs  most  frequently  in  men 
who  have  for  long  been  addicted  to  alcohol,  and  arises  usually 
during  a  fit  of  vomiting  following  in  some  cases — as  in  that 
of  Adams's  and  Morley's— a  heavy  meal.  The  symptoms  in 
this  class  of  cases  contrast  somewhat  with  those  of  the  pre- 
ceding class.  There  being  no  preliminary  violent  exhaustive 
efforts  at  expulsion,  the  symptoms  of  rupture  are  not  masked 
in  any  way  and  at  once  manifest  themselves.  The  patient 
becomes  suddenly  faint.  The  face  is  anxious  and  pale,  and 
suffused  with  perspiration  ;  the  pulse  is  feeble  and  quickened  ; 
the  respiration  is  shallow  and  somewhat  rapid.  There  may 
be  fruitless  attempts  to  vomit ;  possibly  some  dysphagia,  and 
pain  more  or  less  localised.  The  symptoms  may  increase,  and 
the  patient  die  in  a  collapsed  condition  within  a  few  hours. 
Should,  however,  the  primary  shock  be  rallied  from,  later  sym- 
X^toms  may  arise  from  the  escape  of  material  through  the  seat 
of  rupture  into  the  parts  around.  These  complications  will  be 
of  a  septic  character,  and  may  cause  death  within  a  few  days. 

Little  need  be  said  of  treatment.  The  same  reference  may 
be  made,  as  in  the  preceding  class,  to  what  is  indicated  under 
Internal  Injuries. 

In  both  these  classes  of  rupture,  the  lesion  in  the 
oesophagus  has  usually  been  found  to  be  of  a  longitudinal  slit- 
like character,  situated  in  the  thoracic  portion  and  at  some 
little  distance  from  the  diaphragm.  There  is,  however,  no 
special  reason  for  the  rupture  occurring  more  at  one  point  than 
another ;  the  determining  causes  are  probably  the  site  of 
impaction  and  the  existence  of  a  previously  weakened  area. 
In  the  same  way  the  length  of  the  lesion  will  be  determined  by 
the  force  of  expulsion  and  by  the  extent  of  weakness ;  thus 
in  Adams's  case  it  was  only  a  quarter  of  an  inch  long,  while 
in  Fitz's  it  was  two  inches. 

(3)  The  third  class  of  cases,  consisting  of  those  in  which 
rupture  has  occurred  in  an  oesophagus  weakened  by  gastric 
solution,  is  of  comparatively  little  surgical  interest.  The 
accident  occurs  probably  a  few  hours  before  death,  and  is  the 
direct  result  of  an    attack    of   vomitino-.     The    two   cases  of 


16  THE    rESOPHAGUS 

Stanley  Boyd  already  cited  are  illustrations  of  this  form  of 
rupture.  The  specimens  of  these  two  cases  shown  at  the 
Pathological  Society  were  submitted  for  examination  to  a 
committee,  and  the  report  presented  by  Goodhart  and  Butlin 
was  as  follows  :  '  We  think  the  specimens  may  serve  to  call 
attention  to  the  occurrence  of  gastric  solution  during  the 
enfeehlement  immediately  preceding  death ;  an  occurrence 
which  is  probably  not  very  common,  which  has  never  yet 
been  adequately  described,  and  which  has  produced  within 
our  knowledge  the  most  puzzling  appearances.' 


CHAPTER  III 

FOREIGN    BODIES    IMPACTED    IN    THE    (ESOPHAGUS 

Compared  with  either  disease  or  injury  the  impaction  of  foreign 
bodies  in  the  oesophagus  occupies  by  far  the  larger  part  of  the 
surgery  of  this  region.  Little  or  nothing  purely  surgical  may 
be  needed  in  cases  of  disease  or  injury,  but  the  existence  of  an 
impacted  foreign  body  usually  calls  at  some  time,  either  early 
or  late,  for  surgical  interference.  The  accident  is  one  which 
may  happen  to  any  person,  but  children  and  insane  people 
form  a  class  more  prone  to  it  than  any  other.  In  children  it 
is  usually  the  result  of  a  body  which,  either  in  play  or  as  a 
common  habit  in  early  life,  has  been  put  into  the  mouth,  and 
then  got  too  far  back  to  be  checked  in  its  passage  downwards  by 
any  voluntary  effort  at  ejection.  Once  beyond  the  fauces  the 
involuntary  act  of  deglutition  is  brought  into  play,  and  if  the 
body  escape  lodgment  in  the  lower  part  of  the  pharynx,  it 
passes  on  to  become  impacted  in  the  oesophagus.  In  the  case 
of  insane  people  the  act  is  a  voluntary  one.  The  patient,  from 
some  aberrant  motive,  attempts  to  swallow  a  body  which  fre- 
quently, from  its  irregular  shape  and  hard  consistency,  readily 
becomes  impacted.  In  the  case  of  sane  adults,  the  nature  of 
the  substances  is  usually  that  of  some  article  of  diet.  False 
teeth,  however,  are  occasionally  dislodged  and  swallowed  ;  and 
accidents  sometimes  happen  when  foreign  bodies  are  inserted 
into  the  mouth  for  purposes  of  concealment. 

Nature  of  body  impacted. — While  it  is  of  the  utmost  import- 


impacti-:d  foreign   j^odter  17 

ance  to  the  surgeon  to  know  the  nature,  shape,  size,  and 
consistency  of  the  body  impacted,  there  is  not  much  to  be 
gained  by  an  enumeration  of  the  various  substances  that 
from  time  to  time  have  been  recorded  as  becoming  impacted 
in  the  gullet.  When  it  is  remembered  that  insane  people  may 
swallow  the  most  unlikely  objects  and  that  in  children  any 
plaything  may  prove  the  obstructing  agent,  little  gain  would 
be  got  by  giving  a  list  of  these  bodies.  I  would,  however, 
refer  the  reader,  who  may  wish  information  on  this  point,  to 
an  exhaustive  table  compiled  by  Poulet,  and  recorded  in  his 
work ; '  and  also  to  Morell  Mackenzie's  work,  where  a  similarly 
extensive  enumeration  is  given. ^  Under  the  head  of  Treat- 
ment certain  bodies  will  be  singled  out  which  call  for  special 
measures  for  their  extraction  or  dislodgment. 

Seat  of  impaction. — While  any  part  of  the  oesophagus  may 
become  the  seat  of  lodgment  of  a  foreign  body,  there  are 
certain  regions  where  it  more  frequently  happens.  These  are 
the  upper  and  lower  ends — opposite  the  cricoid  cartilage  and  at 
the  diaphragm — and  where  the  left  bronchus  passes  across. 
At  these  spots  not  only  is  the  gullet  narrower,  but  there  is  not 
the  same  proportional  amount  of  distensibility  admitted. 

Symptoms. — The  symptoms  which  arise  in  connection  with 
the  impaction  of  a  foreign  body  vary  within  considerable 
limits.  In  the  simplest  case  there  may  be  no  other  indica- 
tion of  impaction  beyond  a  certain  ill-defined  feeling  of  dis- 
comfort ;  while  in  the  severest  instance  death  may  almost 
immediately  result  either  from  direct  pressure  on  the  trachea 
producing  asphyxia,  or  reflex  laryngeal  spasm  causing  a 
similar  result.  As  an  illustration  of  sudden  death,  Mcllraith  ^ 
reports  the  case  of  a  child  aged  17  months  in  whose  oeso- 
phagus a  piece  of  gristle  became  impacted  during  a  fit  of 
coughing.  Death  resulted  from  asphyxia.  The  bolus  was 
found  pressing  on  both  bronchi,  completely  occluding  the  left 
and  partially  the  right.  Between  these  limits  of  sudden  death 
and  only  slight  discomfort  an  extensive  series  of  symptoms 
may  manifest  themselves,  either  local  or  general,  immediate 
or  remote,  and  most  of  them  will  be  determined  by  the  size, 

'  On  Foreign  Bodies  in  Surgery,  vol.  i.  p.  71. 
-  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  186. 
'  Lancet,  1892,  vol.  ii,  p.  003. 


18  THE    (ESOPHAGUS 

shape,  and  consistency  of  the  body  impacted.  A  large  body 
blocking  the  canal  will  give  rise  to  violent  symptoms  connected 
mostly  with  persistent  and  exhausting  endeavours  on  the  part 
of  the  patient  to  eject  it.  Not  only  will  there  be  aphagia  but 
possibly  also  aphonia,  with  difficulty  in  respiration,  inspira- 
tion being  affected  more  than  expiration.  Pain  may  be  felt 
either  behind  or  in  front,  and  corresponding  more  or  less  to 
the  seat  of  impaction ;  in  some  instances  the  pain  is  referred 
to  a  region  more  or  less  remote  from  the  seat  of  impaction,  as 
in  Maclntyre's  case,'  where  the  foreign  body  was  impacted  in 
the  lower  part  of  the  neck,  and  the  pain  was  felt  at  the  '  pit 
of  the  stomach.'  The  patient  will  frequently  endeavour  to 
vomit,  and  these  futile  attempts  will  as  frequently  end  in  severe 
attacks  of  retching.  There  will  be  great  anxiety,  with  pos- 
sibly the  production  of  various  reflex  spasms  and  neuralgic 
affections.  Flexion  of  the  neck  was  observed  in  one  case 
(Cabot).  In  cases  where  there  is  some  likelihood  of  laceration 
of  the  lining  wall,  from  the  irregularity  and  hardness  of  the 
impacted  body,  haemorrhage  to  a  greater  or  less  extent  may 
follow.  Should  the  endeavour  of  the  patient  culminate  suc- 
cessfully in  the  dielodgment  of  the  body  either  upwards  or 
downwards,  the  more  violent  symptoms  will  at  once  begin  to 
subside,  but  the  sense  of  some  impaction  may  still  linger.  As 
already  indicated,^  rupture  of  the  oesophagus  may  result 
during  the  violent  endeavours  at  expulsion.  In  cases  of  a  less 
severe  nature,  where  total  obstruction  has  not  been  produced, 
the  symptoms  will  be  much  less  marked.  A  sharp-pointed 
body,  as  a  pin  or  fish  bone,  may  give  rise  to  a  pricking  sensation 
at  the  seat  of  impaction,  accentuated  by  any  endeavour  on  the 
part  of  the  patient  to  dislodge  it.  Dysphagia  may  exist,  as 
also  retching  and  vomiting. 

Such  may  be  said  to  be  the  symptoms  arising  at  the  time  of 
the  accident,  and  they  constitute  the  only  symptoms  should  the 
body  be  successfully  removed  within  a  comparatively  short  time 
from  its  first  impaction.  If,  however,  the  period  be  lengthened, 
either  from  inability  to  dislodge  the  body,  or  from  the  fact  of 
the  immediate  symptoms  passing  off  so  that  the  patient  is  led 
erroneously  to  believe  that  it  has  been  removed,  other  symptoms 

'  See  page  24,  2  See  page  11. 


PLA'lE    !. 


..>' 


% 


^^^ 


Fig.  I.— Half-crown  piece  impacted  in  the  cesophagus,  just  behind  the  left  auricle  of 
the  heart.     {Hunterian  Museum,  University  of  Glaigow.) 


IMPACTED    FOREIGN    BODIES  19 

will  arise  depending  upon  the  nature  of  the  lesion  secondarily 
induced. 

Case  VII. — Coin  impacted  in  the  cesojyJiagus  :  symptoms  not  urgent  at 
first,  hut  developing  later. 
A  child  aged  2  whilst  plaj'ing  with  a  halfpenny  accidentally  swallowed 
it.  The  symptoms  at  the  time  not  being  urgent,  matters  were  left  alone. 
In  the  meantime  he  became  gradually  worse,  losing  flesh  and  experi- 
encing some  difficulty  in  swallowing.  Twenty-eight  days  after  the  mishap 
he  was  brought  into  hospital  suffering  from  dysphagia  and  a  short  dry 
cough,  complainmg  always  of  a  fixed  pain  at  the  lower  portion  of  the 
sternum.  When  he  was  given  some  water  to  drink,  it  could  not  be 
swallowed  without  an  effort.  Solids  he  refused.  The  coin  was  removed 
by  the  probang,  and  all  symptoms  subsided.  (Hugh  Thomas,  '  Brit.  Med. 
Journ.'  1879,  vol.  ii.  p.  891.) 

In  this  case  it  is  possible  that  some  slight  ulceration  may 
have  taken  place  at  the  seat  of  impaction,  with  inflammatory 
exudation  around.  Had  the  coin  not  been  removed,  it  might 
have  lead  to  perforation.  Such  was  the  result  in  a  case 
reported  by  Chaffey.'  The  child,  aged  3  years,  swallowed 
a  coin — a  halfpenny.  No  symptoms  occurred  at  the  time, 
and  none  till  two  months  after,  when  the  child  brought  up  a 
little  blood  ;  this  was  followed  a  few  hours  after  by  a  second 
attack  of  haemorrhage,  when  the  child  succumbed.  At  the 
post  mortem  it  was  found  that  the  coin  lay  in  a  cavity  on  the 
right  side  of  the  oesophagus.  The  cavity  was  about  the  size 
of  a  walnut,  and  situated  just  below  the  right  sterno-clavicular 
articulation.  A  communication  was  found  between  the  cavity 
and  the  innominate  artery. 

If  we  bear  in  mind  the  various  structures  and  tissues  in 
anatomical  relation  to  the  oesophagus,  it  is  not  difficult  to  conjec- 
ture what  may  be  some  of  the  complications  likely  to  result  from 
an  ulcerative  perforation  of  the  canal.  Indeed  it  may  be  said 
that  cases  have  been  recorded  illustrative  of  almost  every  one 
of  these  possible  complications.  Taking  them  more  or  less  in 
order  of  importance,  first  may  be  mentioned  imfiammation,  with 
symptoms  of  fever  and  wasting,  then  ulceration,  sloughing,  or 
abscess.  In  these  cases  the  walls  of  the  oesojjhagus  and  the 
neighbouring  cellular  tissue  may  be  alone  involved.  In  some 
cases  the  surface  lesion  has  led  to  septicaemia  and  pyaemia. 

'  British  Medical  Joiirnal,  1895,  vol.  i.  p.  978. 

c  2 


20  THE    CESOPHAGUS 

Ulceration  may  extend  deeply  and  lead  to  perforation  of  the 
pleural  or  pericardial  cavity,  with  symptoms  of  purulent  in- 
flammation of  these  cavities.  In  a  case  reported  by  Silver  ^ 
death  resulted  from  acute  pericarditis,  the  result  of  swallowing 
false  teeth.  At  the  post  mortem  three  or  four  teeth  and  the 
plate  were  lodged  partly  in  the  oesophagus  and  partly  in  the 
pericardial  cavity.  Again,  if  the  body  be  sharp  pointed,  it 
may  itself  be  the  direct  means  of  perforating  these  cavities, 
and  their  contained  organs,  the  heart  and  the  lungs. 
Similarly  perforation  may  take  place  into  the  trachea  or 
leffc  bronchus,  producing  violent  respiratory  symptoms.  The 
spinal  cord  may  be  wounded.  In  cases  of  moderate  hsemor- 
rhage  the  bleeding  may  come  from  oesophageal  vessels  or 
a  thyroid  branch  ;  in  the  severer  cases  one  of  the  large  vessels 
may  be  opened,  such  as  the  aorta,  either  vena  cava,  the 
innominate,  the  common  carotid,  the  right  subclavian,  or  the 
pulmonary  artery.  Should  the  body  be  finally  ejected  by 
abscess  formation  bursting  on  the  surface  of  the  body,  fistulse 
may  remain  or  oesophageal  stricture  result. 

In  illustration  of  some  of  these  complications  the  following 
brief  abstract  of  cases  may  be  given. 

Case  VIII. — Impaction  of  a -piece  of  vieat  in  the  oeso]jhagus,  and  death 
from  abscess  causing  dyspnoea. 

Mrs.  H.,  when  at  supper,  swallowed  a  piece  of  gristle,  with  meat 
attached.  It  was  described  as  being  about  one  inch  long  and  half  an  inch 
in  diameter.  The  symptoms  were  pain  and  sense  of  obstruction  referred 
to  a  point  corresponding  to  the  upper  jjart  of  the  sternum.  A  feeling  of 
uneasiness,  which  later  became  pain,  existed  over  the  spinous  process  of 
the  first  dorsal  vertebra.  There  was  dysphagia  which  amounted  to  a 
total  inability  to  swallow  solids,  and  fluids  only  passed  slowly  and  in  small 
quantities,  with  the  appearance  of  great  muscular  effort.  Pulse  110  ;  skin 
moist ;  expression  of  face  anxious ;  no  difficulty  in  breathing.  Emetics 
were  tried  ineffectually.  On  the  following  day  a  probang  was  passed,  and 
after  its  withdrawal  the  patient  felt  at  once  relieved.  The  symptoms, 
however,  still  continued.  On  the  third  day  there  was  feeling  of  chilliness, 
with  fever  ;  neuralgic  pain  in  the  teeth  and  lower  jaw ;  expectoration 
streaked  with  blood.  On  the  seventh  day  the  patient  suffered  from 
severe  attacks  of  dyspnoea.  Pulse  120  ;  respiration  20.  Breathing  stridu- 
lous,  with  a  somewhat  croupy  cough.  Swallowing  induced  an  attack  of 
dyspncea.     A  slight  bulging  was  found  on  both  sides  of  the  neck,  but  no 

'  Kew  York  Medical  Journal,  1891,  vol.  liv.  p.  609. 


IMPACTED    FOREIGN    BODIES  21 

evidence  of  fluctuation.  The  patient  died  from  a  severe  attack  of  dys- 
pnoea. At  the  post  mortem  the  oesophagus  was  found  to  present  signs  of 
inflammation  on  its  inner  surface.  Behind,  an  abscess  was  found  extending 
from  the  fourth  cervical  vertebra  to  the  second  dorsal  below.  It  con- 
tained about  four  ounces  of  pus.  No  foreign  body  was  discovered.  (Van 
de  Wasker,  '  New  York  Med.  Journ.'  April  1871,  vol.  xiii.  p.  453.) 

Case  IX. — Perforation  of  the  cesophagus  hy  a  fish  hone.     Post-cesopha- 
geal  abscess,  and  death  from  j^ycemia. 

A  woman  was  admitted  into  the  fever  ward  suffering  from  what  was 
supposed  to  be  typhus.  Subsequently  it  was  ascertained  that  a  fish  bone 
had  been  swallowed  some  days  before,  but  a  surgeon  to  whom  the  patient 
at  this  time  apphed  told  her  it  had  been  removed,  and  she  herself  was  of 
the  same  opinion.  The  symptoms  were  in  the  main  those  of  double 
pneumonia,  with  a  peculiar  larjTigeal  cough.  The  weakness  of  the  patient 
did  not  permit  of  much  examination  nor  of  active  treatment.  She  died 
fortj^-eight  hours  after  admission.  The  post  mortem  showed  that  the  bone 
had  passed  quite  through  the  back  wall  of  the  cesophagus.  It  was  found 
imbedded  in  pus  in  front  of  the  vertebral  column.  Pus  was  found  in  the 
pleurge,  m  the  lungs,  and  in  the  pericardium.  (Prof.  W.  T.  Gairdner, 
'  Edin.  Med.  Journ.'  1859,  vol.  iv.  part  2,  p.  769.  See  also  a  case  by  Church 
in  '  St.  Bart.'s  Hosp.  Reports,'  1883,  vol.  xix.  p.  51.) 

Case  X. — Imp)action  of  a  mass  of  meat,  and  perforation  of  the  oesophagus 
hy  a  piece  of  hone.     Extensive  emphysema  and  death. 

D.  G.,  aged  50,  admitted  suffering  from  severe  dyspnoea.  While 
eating  his  dinner  a  piece  of  beef  became  impacted.  He  suffered  much 
pain  at  the  time.  He  was  unable  to  swallow  anything  but  a  little  water. 
His  breathing  soon  became  difficult.  An  endeavour  was  made  to  push 
down  the  mass,  but  without  effect.  The  pain  grew  worse  in  the  evening, 
and  he  noticed  that  his  neck  and  face  had  commenced  to  swell.  The 
following  day  his  symptoms  had  mcreased ;  the  emphysema  was  more 
extensive,  the  breathing  was  strident,  his  voice  was  low  and  husky,  and 
he  had  a  short  gasping  cough.  Later  in  the  day,  owing  to  the  severity  of 
his  symptoms,  he  was  tracheotomised,  with  the  result  that  he  obtained 
much  relief.  On  the  morning  of  the  third  day  the  patient  stated  he  had 
passed  a  very  good  night,  that  his  breathing  was  no  longer  troublesome, 
and  that  the  mass  had  passed  down  his  oe.rophagus  all  right.  He  had  taken 
afterwards  half  a  pint  of  beef  tea.  He  remained  well  throughout  the  day, 
but  towards  night  he  became  weak,  and  weakness  increasing  he  died 
early  the  next  morning — on  the  fourth  day.  At  the  post  mortem  it  was 
found  that  the  posterior  mediastinum  contained  over  a  pint  of  fluid,  which 
was  made  up  ajDparently  of  tea  and  beef  tea.  No  orifice  was  found  in  the 
trachea  except  that  made  at  the  operation.  In  the  oesophagus  a  mass  of 
beef  and  fat  was  found,  and  projecting  through  the  wall  a  small  bone, 
sharp  at  both  ends  and  transfixed  obliquely.  One  end  of  the  bone  per- 
forated the  wall,  and  connected  with  it  and  continuing  upwards  was  a 


22  THE    (ESOPHAGUS 

slit  or  tear  of  one  centimeter  in  length.  It  was  through  this  opening  that 
the  fluids  had  escaped  and  through  which  the  air  had  passed  during  the 
convulsive  efforts  of  the  patient.  (William  Thomson, '  Trans,  of  the  Eoyal 
Acad,  of  Med.  in  Ireland,'  1886,  vol.  vi.  p.  115.) 

Case  XI. — Perforation  of  the  aorta  hy  a  piece  of  hone  impacted  in  the 
oesophagus.     Death  from  hcemorrhage, 

A  man  while  eating  a  chop  swallowed  a  piece  of  bone.  Pain  was  ex- 
perienced afterwards  in  -swallowing,  but  medical  aid  was  not  sought  until 
the  third  day.  Examination  with  the  finger  and  the  horsehair  probang — 
the  latter  being  passed  the  whole  length  of  the  oesophagus — failed  to  detect 
any  foreign  body.  Six  days  after  the  accident  the  patient  was  feeling 
better,  but  the  pain  on  swallowing  had  not  entirely  ceased.  On  the  seventh 
day,  in  the  morning,  he  expectorated  a  small  quantity  of  blood,  and  about 
midday  a  large  quantity  of  arterial  blood  was  thrown  up,  and  death 
followed  immediately.  At  the  post  mortem  a  perforation  was  found  on 
each  side  of  the  oesophagus  at  the  same  level,  that  on  the  left  side  piercing 
the  aorta  an  eighth  of  an  inch  above  the  first  right  intercostal  branch. 
(Williams,  '  Brit.  Med.  Journ.'  1892,  vol.  i.  p.  277.  See  also  similar  cases 
in  '  Brit.  Med.  Journ.'  1879,  vol.  ii.  p.  732  ;  '  Trans.  Path,  and  Clin.  Soc. 
Glasgow,'  1892,  vol.  iii.  p.  27  ;  '  Journal  of  Laryngology  and  Rhinology,' 
1891,  vol.  V.  p.  116.) 

Case  XII. — Perforation  of  the  oesophagus  by  an  impacted  fish  bone. 
Death  from  injury  to  the  heart. 

A  man  aged  59  ate  while  intoxicated  some  fish.  The  next  morning 
he  complained  of  pain  in  the  throat,  as  if  something  were  sticking  there, 
and  he  suffered  from  dysphagia.  During  the  day  he  followed  his  usual 
occupation  and  carried  a  basket  of  fruit  weighing  some  thirty  pounds  for 
some  distance.  Suffering  considerable  pain  in  the  throat  and  chest,  he 
went  in  the  evening  to  the  nearest  hospital,  where  a  dilating  horsehair 
probang  was  passed.  On  leaving  the  hospital  the  man  was  extremely 
faint  and  ill,  and  complained  of  severe  pain  in  the  chest — as  he  expressed 
it,  '  in  his  heart.'  This  pain  increased,  and  he  vomited  nearly  all  food. 
On  the  third  day  after  that  on  which  he  went  to  the  hospital  the  pain  had 
slightly  diminished,  but  the  vomiting  continued.  There  was  no  difficulty 
in  breathing.  Late  in  the  evening  he  got  out  of  bed,  stood  upright  and 
spread  out  his  arms,  stretching  himself.  He  suddenly  staggered ;  his 
wife  ran  to  support  him,  when  he  immediately  expired.  At  the  post 
mortem  it  was  found  that  a  lance-shaped  fish  bone,  about  two  inches  long, 
had  penetrated  the  anterior  surface  of  the  oesophagus  about  a  quarter  of 
an  inch  above  the  cardiac  orifice.  It  passed  through  the  diaphragm  and 
pericardium,  wounding  the  wall  of  the  left  ventricle.  The  pericardial 
cavity  was  fuUy  distended  with  sanious  serum,  and  contained  some  blood 
clot.  Death  was  evidently  due  to  syncope  from  embarrassment  of  the 
heart's  action  by  the  pericardial  effusion.  (Eve,,  '  Chn.  Soc.  Trans.  Lond.' 
1880,  vol.  xiii.  p.  174.) 


IMPACTED    FOREIGN    BODIES  23 

In  this  case  it  is  interesting  to  note  that  the  man's 
worst  symptoms  all  seemed  to  date  from  the  passage  of  the 
probang,  and  such  being  the  case,  one  is  forced  to  the  un- 
pleasant conclusion  that  the  endeavour  to  do  good  had  been 
the  means  of  accelerating,  if  not  possibly  actually  causing,  the 
death  of  the  patient. 

Case  XIII. — Imj^action  of  a  fish  hone  in  the  oesophagus  :  'perforation  of 
an  intervertehral  substance  arid  injury  to  the  spinal  cord. 

A  fish  bone  had  accidentally  been  swallowed  by  an  infant.  A  careful 
examination  failed  to  detect  it.  The  child  gradually  wasted  away,  and 
when  it  died  at  the  end  of  some  months,  it  was  found  that  the  fish  bone 
had  passed  through  the  intervertebral  substance  and  wounded  the  cord. 
(Morell  Mackenzie,  op.  cit.  vol.  ii.  p.  192.  See  also  a  siinilar  case  in  the 
'  Trans.  Path.  Soc.  Lond.'  1853,  vol.  iv.  p.  27.) 

Diagnosis. — From  the  symptoms  described  and  the  cases 
quoted  it  will  be  seen  that  much  latitude  exists  in  the  degree 
of  certainty  which  can  be  attached  to  any  supposed  case  of 
impaction  of  a  foreign  body  in  the  gullet.  While  on  the  one 
hand  no  difficulty  whatever  may  be  present,  on  the  other  it 
may  be  quite  impossible  to  say  whether  the  body  is  still 
impacted  or  has  been  dislodged.  Whenever  it  is  possible  to 
obtain  reliable  information  of  the  occurrence  of  the  accident, 
considerable  assistance  is  lent  towards  making  a  diagnosis, 
notwithstanding  the  obscureness  of  the  symptoms  otherwise. 
In  the  case  of  young  children  and  insane  people,  the  symptoms 
are  often  the  only  indication,  and  if  thefe  be  not  distinctive 
the  diagnosis,  if  not  impossible,  may  be  very  difficult.  As 
regards  the  seat  of  impaction,  information  may  be  obtained 
from  other  sources  than  those  which  the  patient  may  be  able 
to  indicate.  Thus  in  the  neck  a  body  of  sufficient  size  may 
be  felt  by  palpation.  Lower  down,  auscultation  over  the  spine 
may  prove  of  service ;  the  sound  produced  by  the  impact  of 
fluid  in  deglutition  indicating  both  the  existence  and  the  seat 
of  obstruction.  Better  still,  the  passage  of  a  bougie  or  sound 
which  will  give  evidence  of  some  hindrance  to  its  passage. 
Where  a  '  knobbed '  bougie  is  used,  the  metal  or  ivory  knob 
may  be  heard  to  strike  the  body.  Q^.sophagoscopy  has  in 
many  instances  proved  of  value.  Thus  Von  Hacker  ^  is  reported 
to  have  seen  by  the  aid  of  the  panelectroscope  an  irregular 

'  Annual  of  the  Universal  Medical  Sciences,  1890,  vol.  iv.  F— 27. 


24  THE    (ESOPHAGUS 

fragment  of  bone  impacted  in  the  gullet  just  above  the  bifur- 
cation of  the  trachea,  and  detached  it  by  appropriate  screw- 
ing motions.  This  surgeon  has  more  recently  reported  the 
results  of  a  large  number  of  examinations  effected  by  means  of 
the  Mikulicz -Leiter  electro-endoscope,  with  special  regard  to 
the  detection  of  foreign  bodies.  An  abstract  of  these  will  be 
found  in  the  '  Journal  of  Laryngology.'  ^  Morell  Mackenzie  ^ 
also  quotes  a  case  in  which  he  was  enabled  to  detect  a  flat 
lamella  of  bone  on  the  anterior  wall  of  the  oesophagus,  about 
two  inches  below  the  cricoid  cartilage.  It  was  easily  removed 
by  forceps. 

It  must  be  remembered  that  even  in  cases  where  no  doubt 
exists  as  to  the  occurrence  of  such  an  accident  and  marked 
symptoms  are  present,  yet  difficulties  may  stand  in  the  way 
of  an  accurate  diagnosis.  For  on  the  one  hand  there  may  be 
no  obvious  sense  of  obstruction  felt  by  the  patient,  and  the 
passage  of  a  bougie  may  also  fail  to  detect  the  impacted  body. 
Again,  a  body  may  be  successfully  pushed  on  into  the  stomach, 
without  any  immediate  abatement  of  the  symptoms. 

It  is  impossible  to  over-estimate  the  value  which  attaches 
to  the  use  of  the  '  new  photography  '  in  the  detection  of 
foreign  bodies  impacted  in  the  oesophagus.  Not  only  will 
much  of  the  past  difficulty  disappear  in  the  certainty  with 
•which  the  existence  of  a  foreign  body  will  be  verified,  but 
the  whole  subject  of  treatment  will  become  simplified  by  the 
knowledge  of  the  shape,  situation,  and  lie  of  the  object. 
Probably  the  first  case  published  illustrative  of  its  value 
from  a  diagnostic  point  of  view  is  that  of  H.  Entherfurd  and 
J.  Maclntyre,^  of  Glasgow.  The  patient  had  swallowed  a 
halfjDenny  six  months  before,  and  the  pain  felt  was  referred 
to  the  left  of  the  epigastrium.  On  examining  by  means  of 
the  fluorescent  screen,  the  author  could  easily  see  the  round 
black  shadow  of  the  coin  at  the  level  of  the  third  dorsal 
vertebra.  The  case  was  also  photographed  (see  Plate  II, 
fig.  2),  but  the  foreign  body  could  as  easily  be  seen  by  the  eye 
through  the  cryptoscope  or  fluorescent  screen. 

Prognosis. — The  many  possibilities  which  exist  as  long  as 

'  1895,  vol.  ix.  p.  284.  -  Op.  cit.  vol.  ii.  p.  193. 

3  Brit.  Med.  Journ.  1896,  vol.  i.  p.  1094.     See  also  J.  William  While  for 
similar  case.     Annals  of  Surgery,  1896,  vol.  xxiv.  p.  238, 


PLATE    II. 


Fig. 


-A   half -penny   impacted   in    the   (Esophagus. 
Dr.  John  Macintvrc,  Glasgow.) 


(From   a    Skiagraph   taken  by 


IMPACTED  FOREIGN  BODIES  25 

a  body  remains  impacted  in  the  oesopliagus  render  it  impossible 
to  say  what  may  be  the  ultimate  result  in  any  one  case.  The 
first  considerations  of  importance  are  the  nature  of  the  im- 
pacting body  and  the  urgency  of  the  immediate  symptoms. 
As  a  rule  there  is  a  direct  relation  between  these  two  con- 
ditions. The  larger,  harder,  and  more  irregular  the  substance 
impacted,  the  graver  will  be  the  symptoms,  and  if  in  these 
severer  cases  immediate  relief  is  not  afibrded  by  removal  of 
the  body,  a  fatal  result  rapidly  ensues.  A  successful  dis- 
lodgment,  however,  of  the  obstructing  material  is  quickly 
followed  by  complete  abeyance  of  all  symptoms.  The  excep- 
tions to  this  latter  result  are  those  comparatively  rare  cases  of 
rupture  of  the  oesophagus  '  occurring  at  the  time  of  ejection  of 
the  body.  When  the  symptoms  are  not  urgent  at  the  first, 
the  prognosis  again  turns  upon  the  nature  of  the  impacting 
body  and  whether  it  is  likely  to  be  dislodged  by  operative 
measures  or  by  natural  processes.  The  more  a  substance 
approaches  something  which  is  likely  to  stick  into  the  walls  of 
the  gullet,  the  less,  speaking  generally,  is  the  chance  of  its 
removal  either  naturally  or  by  operation.  Again,  the  longer 
such  a  body  remains  impacted  the  graver  becomes  the  pro- 
gnosis. The  cases  already  quoted  sufficiently  indicate  the 
gravity  of  prolonged  lodgment  of  these  sharp-pointed  bodies. 
While  therefore  it  must  always  give  cause  for  anxiety  as 
long  as  bodies  of  this  description  are  within  the  oesophagus, 
nevertheless  not  a  few  cases  are  now  on  record  showing  that, 
at  periods  of  variable  length  from  the  date  of  the  accident, 
dislodgment  has  taken  place  and  complete  recovery  resulted. 
In  a  case  recorded  by  Lennox  Brown, ^  a  toothplate  which 
had  been  impacted  for  three  and  a  half  years,  and  had  given 
rise  throughout  to  gradually  increasing  difficulty  in  swallowing, 
was  successfully  removed  by  means  of  a  coin  catcher.  It 
should,  however,  be  stated  that  where  nature  has  been  the 
means  of  gradually  loosening  and  finally  dislodging  the  body 
the  latter  has  been  rather  of  the  nature  of  a  rounded  than  a 
pointed  substance. 

The  loosening  of  the  body,  and   its   dislodgment,    result 
either  from   some   relaxation  of   spasm  or   from  ulceration, 

'  See  page  11. 

-  Journal  of  Laryngologij  and  Rhinologij,  1892,  vol.  vi.  p.  365. 


26  THE    (ESOPIlA(iUS 

after  which  it  may  pass  down  into  the  stomach,  or  be  ejectei 
through  the  mouth  in  a  sudden  violent  attack  of  retching. 
In  other  cases  it  becomes  the  nucleus  of  an  abscess,  which, 
bursting  externally,  is  discharged.  Again,  sharp-pointed  bodies 
such  a  s  pins  and  needles  have  worked  their  way  harm- 
lessly through  the  tissues  and  been  finally  extracted  from 
beneath  the  skin.  Lastly,  the  body  may  become  encysted 
and  remain  perfectly -inert  throughout  life. 

The  following  abstracts  of  cases  may  be  given  in  illustra- 
tion of  some  of  the  natural  processes  of  repair  : 

Case  XIV. — Imjjaction  of  a  coin  in  the  oesoi^hagus :  exjndsion  by  the 
mouth  after  four  months. 

A  bo3'  aged  4  years  while  playing  with  some  money  swallowed  a 
haKpennj'.  An  emetic  was  given  without  effect.  He  was  very  sick, 
cried  a  great  deal,  and  complained  of  pain  which  he  located  about  the 
middle  of  the  sternum.  He  looked  ill  and  lost  his  appetite.  He  was 
very  restless  both  day  and  night.  Some  days  later  he  appeared  to  be 
quite  well,  his  apxDetite  was  good,  but  he  still  complained  of  pain  about 
the  middle  of  the  sternum,  which  was  increased  on  swallowing  anything 
semi-solid.  After  a  few  weeks  the  child  lost  the  pain,  and  forgot  all 
about  the  halfpenny.  Four  months  after,  while  munching  some  cake,  he 
hiccoughed  violently  and  was  surprised  to  find  that  he  had  brought  tip 
the  coin,  which  had  turned  quite  black.  (Doyle,  '  Lancet,'  1888,  vol.  ii. 
p.  911.) 

Case  XV. — Impaction  of  a  toothplate  in  the  oesophagits :  expulsion  by 
the  mouth  after  fifteen  months. 

T.  H.,  aged  28,  awoke  in  the  night  feeling  his  toothplate  slipping  into 
his  throat.  It  passed  beyond  his  being  able  to  eject  it,  and  became  im- 
pacted at  the  top  of  his  gullet,  where  it  could  be  felt.  The  patient  was 
nervous  and  excited,  he  frequently  retched  and  expectorated  blood-stained 
saliva.  Dj'spnoea  and  dysphagia  were  marked.  The  forceps  grasped 
the  plate,  but  in  attemptmg  to  extract  it  the  dyspnoea  increased  and  the 
struggling  of  the  patient  caused  them  to  loose  their  hold.  A  second 
attempt  similarlj'  failed.  Probangs  were  passed  into  the  stomach  without 
meeting  with  any  obstruction  ;  the  patient  was  watched  for  a  few  days 
and  then  discharged,  the  dyspnoea  and  dysphagia  having  disappeared.  A 
few  weeks  afterwards  he  was  again  suffering  from  dj'spnoea,  had  a  hard 
frequent  cough,  and  was  expectorating  copiously  a  tenacious  mucus 
tinged  with  blood.  This  symptom  continued,  until  one  day,  fifteen 
months  after  the  accident,  he  felt  worse  than  usual,  and  after  a  violent 
fit  of  retching  he  felt  something  in  the  back  of  his  throat.  By  means  of 
his  thumb  nail  he  hooked  out  the  false  teeth.  (Bridgeman, '  Lancet,'  1887, 
vol.  ii.  p.  612.) 


IMPACTED    FOEEIGN    BODIES  27 

Case   XVI. — Impaction  of  a  tootlix>late   in  the   oesajjluif/us :  expulsion 
per  anum  five  months  afterwards. 

The  patient  swallowed  a  small  toothplate  with  two  teeth  durinf^  sleep. 
Three  weeks  afterwards  he  consulted  his  doctor  and  an  endeavour  was 
made  to  remove  it.  It  was  felt  by  the  probang  about  ten  inches  down  the 
gullet,  but  two  attempts  to  dislodge  it  failed.  The  patient  declined  opera- 
tion. He  returned  three  weeks  later,  when  it  was  found  that  the  plate 
had  spontaneously  moved  to  eleven  and  a  half  inches.  A  day  or  two 
after  it  had  gone  to  thirteen  inches,  at  which  place  it  remained  for  three 
weeks.  It  then  moved  another  inch,  and  fixed  itself  at  fourteen  mches  for 
a  month.  Finally  it  moved  to  fifteen  and  sixteen  inches  at  intervals  of  a 
day ;  and  at  last  was  pushed  on  into  the  stomach,  after  having  given  rise 
to  some  hours  of  severe  pain.  It  ultimately  passed  per  anum,  having 
sojourned  in  the  gullet  for  five  months.  (Hardie, '  Brit.  Med.  Jom-n.'  1881, 
vol.  i.  p.  276.) 

Case  XVII. — Impaction  of  a  five-centime  piece  in  the  oesophagus.  Death 
from  scarlet  fever  twenty  mo7iths  afterwards.  Coin  found  partially 
encysted. 

A  child  7  years  old  was  admitted  into  the  hospital  complaining  of 
pain  in  swallowing  and  located  at  a  spot  on  a  level  with  the  lower  part 
of  the  thyroid  body.  It  was  stated  that  eighteen  months  previously  she 
had  swallowed  a  halfpenny,  and  that  for  the  last  few  weeks  she  had  been 
constantly  vomiting  and  unable  to  keep  anything  down.  At  the  time  of 
admission  she  could  swallow  milk  naturally.  The  patient  got  on  very 
weU,  and  took  food  without  sickness.  She  was,  however,  attacked  with 
scarlet  fever,  from  which  she  died.  At  the  post  mortem  the  coin,  but  little 
changed,  was  found  lodged  in  a  cavity  situated  between  the  posterior 
wall  of  the  trachea  and  the  anterior  wall  of  the  oesophagus.  The  cavity 
was  lined  by  a  smooth  membrane,  and  opened  above  into  the  oesophagus 
by  an  orifice  which  left  about  one-third  of  the  coin  exposed.  (Sharkey, 
'  Trans.  Path.  Soc.  Lond.'  1884,  voL  xxxvi.  p.  190.) 

Case  XVIII. — Imp)action  of  a  chestnut  in  the  oesophagus.     Death  from 
acute  p)hthisis  fourteen  months  afterwards.     Chestnut  found  encysted, 

M.  L.,  set.  38,  a  lunatic,  swallowed  a  chestnut  with  the  object  of 
putting  an  end  to  her  life.  Her  symptoms  showed  no  acuteness.  She 
refused  for  three  days  to  take  any  food,  except  water,  which  she  swallowed 
with  apparently  the  greatest  difficulty  and  pain.  Nothing  was  detected 
externally,  but  on  attempting  to  pass  a  tube  it  could  not  be  got  any 
further  than  the  entrance  of  the  (jesophagus.  A  thorough  examination 
was  made  under  chloroform.  The  day  following  she  took  milk,  but  still 
with  apparent  difficulty.  After  this  she  ate  bread,  and  from  henceforward 
began  to  improve  and  take  both  solids  and  fluids.  In  March  of  the  fol- 
lowing year  acute  phthisis  developed,  and  she  died  about  fourteen  months 
after  swallowing  the  chestnut.  At  the  post  mortem  both  lungs  were 
studded  with  miliary  tubercles.     On  opening  the  oesophagus  the  chestnut 


28  THE    (ESOPHAGUS 

was  found  in  a  perfect  state  of  preservation,  lying  on  the  fifth  and  sixth 
cervical  vertebrae,  vs^here  it  had  made  a  pocket  for  itself.  (Courtenay, 
'  Joui-nal  of  Mental  Science,'  1888-89,  vol.  xxxiv.  p.  539.) 

Treatment. — In  discussing  the  treatment  to  be  adopted  in 
the  removal  of  foreign  bodies  from  the  oesophagus,  the  con- 
siderations connected  with  it  may  be  said  to  be  on  a  par  with 
those  connected  with  the  diagnosis  of  the  seat  of  impaction 
and  the  nature  of  the  impacted  body.  The  more  accurate 
the  knowledge  of  the  body  and  its  connections,  the  easier 
becomes  the  choice  of  the  most  suitable  method  for  its  removal, 
and  the  more  likely  is  success  to  follow.  The  treatment  there- 
fore to  be  adopted  in  any  case  depends  largely  upon  facts  ascer- 
tained with  regard  to  it.  Without  some  such  consideration 
between  cause  and  treatment,  operation  may  do  more  harm 
than  good.  As  illustrating  how  simple  a  measure  may  bring 
about  even  a  fatal  issue  see  Case  XII.  already  quoted,  where  it 
will  be  found  that  the  passage  of  a  hair  probang  led  appa- 
rently to  the  perforation  of  the  heart  by  a  fish  bone.  Every 
case  therefore  has  to  be  treated  on  its  own  merits,  and  may 
call  for  siDecial  ingenuity  on  the  part  of  the  operator  to  adopt 
measures  suited  for  the  case  under  consideration.  As  then  it 
is  not  possible  to  state  any  general  method  that  should  be 
adopted  in  every  case,  I  shall  simply  describe  the  various 
measures  that  are  in  use,  and  indicate  such  few  as  exist  for 
dealing  with  special  cases. 

Use  of  an  anaesthetic. — The  question  of  the  administration 
of  an  anaesthetic  will  sometimes  arise.  It  has  both  its  advan- 
tages and  disadvantages.  In  the  case  of  children  an  ansesthelic 
admits  of  a  more  careful  examination  of  the  oesophagus, 
and  of  the  adoption  of  any  of  the  milder  measures  for  the  re- 
moval of  the  obstructing  agent.  In  adults  it  removes,  what  is 
sometimes  of  much  assistance,  the  help  that  the  patient  is  able 
to  give  ;  and  it  also  entails  the  patient  being  ia  a  recumbent 
position.  The  question  of  the  giving  of  an  anaesthetic  is  more 
or  less  determined  by  the  amount  of  resistance  which  the  patient 
is  likely  to  offer  to  measures  adopted  either  for  diagnosis  or 
treatment. 

Various  methods  of  treatment :  1.  By  manipidation. — Should 
the  body  be  lodged  in  the  cervical  portion  of  the  oesophagus 
and  be  of  a  soft  nature,  it  may  be  possible  to  alter  its  shape 
so  as  to  admit  of  its  being  ejected.     Or,  again,  it   may  be 


TMPACTED    FOIJETGN    BODIES  29 

possible,  by  manipulating  it,  to  work  it  upwards  or  downwards. 
As  the  finger  cannot  reach  usually  beyond  the  cricoid  cartilage, 
little  good  can  be  effected  by  internal  manipulation.  An  inter- 
esting, though  somewhat  exceptional,  measure  was  adopted  by 
Taylor  of  Hathersage,  who,  in  the  case  of  a  pin  in  the  oeso- 
phagus, induced  a  little  girl  with  small  hand  and  arm  and 
long  tapering  fingers  to  pass  her  hand  down  the  canal,  when 
she  succeeded  in  detecting  the  pin  and  removing  it.' 

2.  By  adininistratioii  of  solid  food. — In  cases  of  such 
bodifs  as  fish  bones,  pins,  &c.,  which  do  not  prevent  degluti- 
tion, it  is  sometimes  possible  to  dislodge  them  by  the  admi- 
nistration of  solid  food.  The  patient  should  be  induced  to 
swallow  reasonably  large  pieces  of  partially  masticated  dry 
crusty  bread  or  masses  of  mealy  boiled  potatoes. 

3.  Bi/  emesis. — Some  judgment  needs  to  be  exercised  in 
deciding  whether  a  patient  should  be  induced  to  vomit  or  not. 
Where  it  is  thought  likely  that  the  impacting  body  might 
perforate  the  walls  of  the  oesophagus  no  vomiting  should  be 
encouraged.  On  the  other  hand,  in  the  case  of  articles  of  diet 
not  likely  to  injure  the  canal,  and  which  have  not  already  led 
to  retching  or  vomiting,  an  emetic  may  be  tried.  The  con- 
sensus of  opinion,  however,  amongst  most  surgeons  is  against 
the  use  of  emesis,  and  at  most  it  should  receive  a  very  limited 
and  guarded  application. 

Emesis  may  be  effected  in  one  of  four  ways  : 
First,   by   administration   of  an   emetic   by  the   mouth. 
This  naturally  can  only  be  accomplished  when  obstruction  is 
not   complete   and   deglutition   is   possible.      The    followino- 
illustrates  a  successful  case  : 

Case  XIX. — Impaction  of  a  jnece  of  hone  in  the  ossoj^hagus  :  ejection  of 
the  hone  hy  induction  of  vomiting. 
A  lady  had  swallowed  a  piece  of  bone  with  some  soup.  She  was  seen 
twenty  hoiu-s  afterwards  in  great  distress,  and  quite  unable  to  swallow 
anything.  The  obstruction  was  quite  beyond  reach.  An  emetic  consist- 
ing of  half  a  drachm  of  sulphate  of  zinc  was  administered.  This  havino- 
no  effect,  a  second  dose  was  given  and  vomiting  immediately  occurred. 
There  was  discharged  through  the  mouth  a  piece  of  mutton  bone  quite 
an  inch  long  and  having  four  sharp  corners  and  edges.  (Glover,  '  Brit. 
Med.  Jom-n.'  1884,  vol,  i.  p.  5G1.) 

'  Solis-Cohen,  Annnal  of  the  Universal  Medical  Sciences,  1888,  vol.  iii. 
p.  327. 


30  ^JIIE    CESOPIIAGUS 

'  Second,  by  an  enema.  An  infusion  of  tobacco,  in  a 
case  quoted  by  Poulet,  was  successful  in  causing  the  ejection 
of  a  piece  of  sheep's  lung  which  had  given  rise  to  serious 
symptoms. 

Third,  by  subcutaneous  injections.  Both  tartar  emetic  and 
hydrochlorate  of  apomorphia  have  been  used  with  success. 
Doses  of  ^  grain  of  the  former  and  -g-V  to  yV  grain  of  the 
latter  may  be  given.  ' 

Case  XX. — Imijaction  of  the  heart  of  a  bird  in  the  oesophagus  :  sub- 
cutaneous injection  of  k  grain  of  tartar  emetic  :  ejection  of  the 
substance  by  vomiting. 

A  lady  aged  32,  whilst  partaking  of  a  giblet  pie,  was  suddenly  seized 
witli  a  choking  sensation,  together  with  difficulty  of  breathing.  The 
patient  was  unable  to  swallow  fluid.  The  probang  indicated  an  obstruc- 
tion five  or  six  inches  from  the  mouth.  Vomiting  was  encouraged  by  the 
administration  of  mustard  and  water  and  by  tickling  the  fauces  with  a 
feather,  but  in  both  cases  without  effect.  Later,  owing  to  an  increape  of 
symptoms  and  an  urgent  desire  to  have  something  done,  10  minims 
(^  grain)  of  the  tartrate  of  antimony  solution  was  injected  into  the  left 
arm.  In  less  than  two  minutes  a  sensation  of  sickness  was  produced,  and 
almost  immediately  afterwards  a  sudden  fit  of  vomiting  came  on,  which 
had  the  effect  of  expelling  a  perfect  specimen  of  the  heart  of  a  bird.  The 
patient  was  at  once  relieved.     (Dodd,  'Lancet,'  1885,  vol.  ii.  p.  713.) 

Case  XXI. — Tmj^action  of  a  piece  of  bone  in  the  oesoi^hagus  :  subcuta- 
neous injection  of  ^^^  grain  of  apomorphia  :  ejection  of  the  bone  by 
vomiting. 

A  strong  Irish  woman,  after  a  hearty  meal  of  mutton  stew,  vomited  a 
little  blood  and  felt  a  sharp  pain  in  her  throat,  especially  with  inspiration 
or  swallowing.  On  external  examination  of  the  neck  something  could  be 
felt  to  grate  and  move  a  little  just  behind  the  cricoid  cartilage.  The  sub- 
cutaneous injection  of  apomorphia  (^V  grain)  caused  vomiting  in  eight 
minutes,  with  the  relief  of  all  symptoms  and  the  removal  with  the  vomit 
of  a  piece  of  sheep's  rib  an  inch  and  a  half  long  and  half  an  inch  wide. 
(Preble,  '  Boston  Med.  and  Surg.  Journ.'  1885,  p.  107.) 

Fourth,  by  mechanical  measures.  Perhaps  one  of  the 
best  means  for  inducing  vomiting,  and  one  which  was  strongly 
advocated  by  Syme,  is  to  irritate  the  back  of  the  throat  with  a 
feather.  In  the  case  of  young  children  it  is  a  very  good  plan 
to  turn  the  child  on  to  its  stomach,  allow  the  chest  to  rest  upon 
a  pillow,  and  then  insert  the  finger  into  the  back  of  the  throat. 
Qhe  child  then  retches,  and  the  foreign  body  coming  up  into 
the  back  of  the  pharynx,  drops  down  out  of  the  mouth.     Coins 


TMrACTEl)     FOIJEIGN     BODIES  31 

and  such  like  bodies  are  often  effectually  got  rid  of  in  this 
way. 

4.  By  solvents. — It  has  been  found  possible  in  some  cases 
of  obstruction  from  large  masses  of  food  to  cause  a  certain 
amount  of  artificial  digestion  of  the  substance,  whereby  it  has 
become  so  softened  that  its  dislodgment  has  been  effected. 
For  the  purpose  pepsine  has  been  given.  A  successful  case 
is  quoted  by  Solis-Cohen  ^  of  a  child  3  years  of  age,  who 
had  a  stricture  the  result  of  drinking  some  lye  eighteen  months 
previously.  The  removal  of  the  foreij^ai  body  was  facilitated 
by  preliminary  softening  with  digestive  mixture. 

5.  By  prohang,  hougie,  or  coin  catcher. — The  most  service- 
able kind  of  probang  is  that  known  as  the  bristle  probang,  or, 
as  it  is  sometimes  termed,  the  horsehair  parasol.  It  is 
fitted  with  a  piece  of  sponge  at  the  extremity,  and  the  bristles 
are  capable  of  being  expanded  into  a  parasol-like  shape  (Hg.  3). 


Fig.  3. — Bristle  Peobang 

This  instrument  can  be  used  either  with  the  object  of  forcing 
the  obstacle  on  into  the  stomach,  or,  as  is  more  frequently  the 
case,  for  extracting  it  by  the  mouth.  In  the  first  instance  the 
probang  will  not  pass  by  the  obstruction,  while  in  the  second 
it  must  do  so.  In  the  passage  of  a  probang  or  bougie  a  few 
anatomical  points  should  be  borne  in  mind.  As  the  result  of 
measurements  taken  in  fifty-five  subjects,  Maurice  H.  Eichard- 
son  showed  that  '  the  distance  from  the  upper  incisors  to  the 
opening  in  the  diaphragm  when  the  head  is  thrown  back  is 
not  constant.  The  average  distance  is  fourteen  and  a  half 
mches.  There  is  also  no  constant  ratio  between  the  height  of 
the  individual  and  the  measurement.  If,  however,  the  indi- 
vidual is  of  average  height  and  with  a  neck  of  ordinary  length, 
it  is  safe  to  say  that  the  distance  from  the  incisors  to  the 
diaphragm  is  about  fourteen  and  a  half  inches.  If  the  probang 
is  arrested  at  a  point  more  than  thirteen  inches  from  the 
incisors,  the  point  of  obstruction  is  probably  at  or  near  the 
cardiac  end  of  the  oesophagus.' 

'  Annual  of  the  Universal  Medical  Sciences,  1888,  vol.  iii.  p.  326. 


32  THE    (ESOPHAGUS 

If  the  probang  passes  by  the  obstruction,  the  parasol  is 
then  expanded  and  withdrawn.  In  using  a  probang  for  pro- 
pulsion purposes,  it  must  be  remembered  that  the  endeavour 
is  not  free  from  danger.  Cases  are  recorded  of  serious  and 
even  fatal  results  from  the  forcible  use  of  the  instrument.  The 
following  is  a  brief  abstract  of  such  a  fatal  case. 

Case  XXII. — Rupture  of  the  aorta,  the  result  of  an  endeavour  to  force 
onwards,  hy  vieans  of  a  probang,  a  toothplate  impacted  in  the 
oesophagus. 

Sir  Andrew  Clark,  at  a  meeting  of  the  Clinical  Society  of  London, 
instanced  a  case  of  Syme's  in  whicli  a  man  had  swallowed  a  toothplate, 
and  in  forcibly  pnshing  it  on  by  means  of  a  probang,  the  surgeon  acci- 
dentally ruptured  the  aorta.  A  rush  of  blood  immediately  took  place  and 
speedily  led  to  the  death  of  the  patient.  ('  Brit.  Med.  Journ.'  1884,  vol.  i. 
p.  561.) 

The  remarks  made  regarding  the  use  of  the  probang  equally 
apply  to  the  employment  of  the  bougie.  It  may  be  useful  to 
remember  that  when  propulsion  suggests  itself  as  feasible,  other 
means  more  readily  at  hand  may  be  used  in  place  of  the  proper 
bougie.  Thus  the  stem  of  a  leek  has  proved  effectual ;  also  a 
whip  handle.  The  coin  catcher  (fig.  4)  is  more  especially  fitted 
for  the  purpose  which  its  name  suggests,  although  it  sometimes 
is  of  service  for  the  extraction  of  other  objects. 


Fig.  4.— Coin  Catcher 

Difficulties  sometimes  arise  in  withdrawing  both  the  pro- 
bang  and  the  coin  catcher.  Such  happen  from  the  locking  of 
the  instrument  with  the  foreign  body.  In  accidents  of  this 
nature  the  instruments  should  be  pushed  down  again  and 
some  slight  rotatory  movement  adopted,  when  another  attempt 
may  be  made  at  withdrawal.  In  no  case  should  force  be  used, 
and  when  all  reasonable  endeavours  fail  at  withdrawal,  oeso- 
phagotomy  will  have  to  be  performed. 

6.  By  forceps. — The  kind  of  foreign  body  for  which  the 
forceps  is  best  suited  is  that  which  is  too  large  and  too  fixed  to 
be  extracted  by  the  probang.  It  is  limited  also  in  its  use — in  the 
simpler  forms — to  obstacles  situated  nearer  the  upper  than 
the  lower  end  of  the  gullet.     In  using  the  forceps,  it  should  be 


IMPACTED   F()in'J(!N   ]',()]) lES 


33 


remembered  that  the  body  to  be  extracted  has  to  be  drawn  up 
through  the  narrower  part  of  the  canal  opposite  the  cricoid 
cartilage,  and  therefore  no  force  should  be  exercised  if  a  hitch 
takes  place  at  that  point. 

Various  kinds  of  forceps  will  be  found  depicted  in  the  text- 
books, many  somewhat  complicated  both  in  their  construct!'  ^n 
and  in  their  use.  The  simplest,  and  for  all  practical  purposes 
the  best,  is  the  long-shanked  (Esophageal  forceps  with  a  slight 
bend  near  the  biting  portion  (see  fig.  5).  This  instrument  can 
only  remove  bodies  from  near  the  upper  end,  and  it  is  a  ques- 
tion whether  with  the  more  complicated  forceps,  made  so  as  to 


Fig.  5. — Oesophageal  Forceps  with  Perpendicular  Curve 

reach  farther  down  the  canal,  it  is  wise  to  withdraw  a  body 
that  is  impacted  in  the  lower  part.  For  although  it  might 
thus  be  removed  without  injury  to  the  canal,  less  risk  would 
probably  be  run  by  gently  pushing  it  on  into  the  stomach,  or 
by  opening  the  cesoj)hagus  in  the  neck  and  attempting  extrac- 
tion through  the  wound.  In  some  cases  it  has  been  found 
possible  to  loosen  the  impaction  of  the  body  by  dilating  the 
oesophagus  either  above  or  below  the  seat  of  obstruction.  For 
this  purpose  a  large-sized  dilator — such  as  is  used,  and  will  be 
described  later,  for  stricture — may  be  passed  down  to  the 
obstruction.  Elastic  bags,  capable  of  inflation  either  by  air  or 
water,  have  been  used  for  the  same  object,  and  on  one  occasion 
with  success.^  In  using  the  forceps  a  gag  is  necessary,  and 
care  should  be  taken  to  see  that  it  is  securely  fixed.  Annan- 
dale  ^  reports  two  cases  in  which  difficulty  occurred  in  attempt- 
ing to  extract  the  foreign  body,  on  account  of  the  gag  slipping 
just  as  the  body  was  opposite  the  orifice  of  the  larynx.  Great 
respiratory  trouble  at  once  ensued,  until  the  mouth  was  forcibly 
opened  and  the  body  extracted. 

'  Gautier,  quoted  by  Poulet,  On  Fordgn  Bodies  in  Surgery,  vol.  i.  p.  116. 
'^  Liverpool  MecUco-Chirurgical  Journal,  1881,  No.  1,  p.  18. 


34  THE   CESOPPIAGUS 

7.  By  adhesive  substances. — A.  very  simple  and  effectual 
method  of  extracting  small  bodies  has  been  practised  with 
success  by  Crequy.'  He  recommends  '  tangling  up  a  skein  of 
thread  and  tying  it  in  the  centre  with  a  strong  thread  forty  to 
fifty  centimeters  long,  covering  the  mass  with  some  agreeable 
confection  and  letting  the  patient  swallow  it ;  as  soon  as  it  is 
supposed  to  have  passed  the  foreign  body  it  is  drawn  out.' 

8.  By, special  means  fur  particular  cases. — The  removal  of  a 
fish  hook  which  has  '  caught '  the  walls  of  the  gullet  calls  for 
a  special  method  for  its  extraction.  In  all  the  cases  recorded 
the  hook  has  been  accidentally  swallowed  while  still  attached 
to  a  piece  of  thread  or  gut ;  and  it  is  this  latter  which  consti- 
tutes the  chief  aid  in  the  process  of  extraction.  The  plan  is 
to  pass  the  line  attached  to  the  hook  through  either  a  solid 
substance  or  a  long  hollow  bougie.  In  the  former  case  the 
weight  of  the  substance,  when  it  has  slipped  down  to  the  hook, 
dislodges  it ;  and  in  the  latter,  as  soon  as  the  hollow  bougie 
reaches  the  hook,  the  force  applied  in  pushing  it  on  causes  the 
hook  to  be  withdrawn.  Two  cases  quoted  by  Morell  Mackenzie  ^ 
illustrate  the  success  attending  each  of  these  methods.  The 
substance  used  in  one  case  was  a  lead  ball  twice  the  diameter 
of  the  hook  ;  in  the  other  it  was  a  full-sized  hollow  oesophageal 
bougie.  The  following  illustrates  a  case  successfully  treated 
by  Syme  : 

Case  XXIII. — Extraction  of  a  fish  hooh  impacted  in  the  oesophagus. 
A  boy  in  the  excitement  of  fishing  swallowed  a  three-barbed  hook  he 
was  holding  in  his  mouth.  A  wire  was  attached  to  the  hook.  Professor 
Syme  adapted  a  wooden  ball  to  fit  the  barbs,  and,  passing  it  along  the  wire, 
succeeded  in  breaking  away  the  points,  after  which  the  hook  was  easily 
removed  and  recovery  ensued.  (Dufiin,  '  Brit.  Med.  Journ.'  1884,  vol.  i. 
p.  561.) 

9.  By  oesophagotomy. — Failing  every  endeavour  to  extract 
the  body  by  the  mouth,  the  question  of  operation  will  arise. 
The  points  to  be  considered  will  be  the  nature  of  the  body — its 
size,  consistency,  and  contour ;  its  position ;  the  urgency  of 
the  symptoms  ;  and  the  remote  possibilities,  whether  it  may 
by  natural  processes  become  dislodged  or  whether  it  may  give 

'  Solis-Cohen,  Annual  of  the   Universal  Medical  Sciences,  1889,  vol.  iv. 
G — 36.  *  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  194. 


I.Ml'ACTKl)    FOlM'JdN    BODIES  35 

rise  to  dangerous  complications.  It  will  thus  be  seen  that  the 
question  of  operation  may  be  one  of  considerable  difficulty  to 
decide.  The  feeling  among  surgeons  nowadays  is  rather  to 
operate  than  delay  when  in  doubt,  and  the  success  which  has 
attended  operative  interference  adds  farther  encouragement 
in  that  direction.  Professor  Kronlein  '  has  opeiated  success- 
fully in  five  cases  out  of  six.  In  the  case  of  a  chdd  aged  3 
years  which  had  swallowed  a  halfpenny,  I  preferred  to  perform 
external  oesophagotomy  to  attempting  to  pull  the  coin  up  by 
the  natural  ways.  As  it  was,  the  coin  was  so  tightly  impacted, 
or  the  muscles  so  closely  contracted  upon  it,  that  much  force 
was  required  to  extract  it  with  a  pair  of  dressing  forceps 
through  the  oesophageal  wound.  It  is  probable  that  many  a 
large  body  will  pass  down  the  oesophagus  without  injuring  the 
walls,  because  its  progress  is  helped  by  the  natural  downward 
contraction  of  the  constrictor  muscles  and  the  circular  muscular 
fibres  of  the  gullet ;  but  when  an  attempt  is  made  to  pull  the 
body  up,  the  same  muscles  which  helped  it  on  now  impede  its 
return  ;  and  hence,  while  the  mucous  membrane  escaped  any 
injury  in  the  downward  course  of  ihe  object,  it  is  liable  to  be 
lacerated — and  possibly  the  other  tunics  also — in  its  forcible 
extraction  upwards.  Much  more  does  this  reasoning  apply  to 
hard,  irregularly  shaped  bodies,  which  are  much  more  likely  to 
produce  serious  injury  to  the  walls  of  the  gullet  than  coins  and 
suchlike  objects.  It  is  useful  to  remember  that  the  finger  in- 
serted into  the  oesophagus  at  the  cervical  wound  can  reach  the 
arch  of  the  aorta,  and  even  hook  the  finger  under  it  in  some 
cases  (Maurice  H.Eichardson).^  Thoracic  oesophagotomy  has 
been  suggested  for  cases  of  impaction  below  the  reach  of  the 
cervical  operation. 

10.  By  gastrotomy. — In  cases  where  the  body  has  become 
impacted  at  the  lower  end  of  tbe  gullet,  and  its  removal  is  con- 
sidered imperative,  it  can  be  successfully  reached  through  the 
stomach.  Brief  extracts  of  two  interesting  cases  are  given  in 
which  this  measure  was  adopted  successfully.  In  the  first  case 
the  body  was  withdrawn  through  the  mouth ;  in  the  second  it 
was  removed  through  the  stomach. 

'  Annals  of  Surgery,  1894,  vol.  xx.  p.  567. 

-  Boston  Med.  and  Surg.  Journ.  1890,  vol.  cxv.  p.  568. 

o2 


36  THE   (ESOPHAGUS 

Case  XXIV. — Imjpaction  of  a  peach  stone  in  the  oesophagus  :  successful 
removal  through  the  mouth  by  the  aid  of  gastrotoniy. 
A  boy  aged  4  years  had  a  peach  stone  impacted  in  his  gullet  at  a 
distance  of  thirteen  inches  from  his  teeth.  After  opening  the  abdomen  an 
incision  an  inch  and  a  quarter  long  was  made  into  the  stomach ;  through 
this  the  index  finger  was  inserted  and  passed  into  the  oesophagus,  where  the 
stone  was  felt.  A  slender  bougie  was  then  inserted  through  the  stomach 
into  the  oesophagus,  past  tlie  foreign  body,  and  out  of  the  mouth.  A  piece 
of  sponge  was  fastened  to  the  lower  end  of  the  bougie,  and  on  the  with- 
drawal upwards  of  the  latter,  the  stone  was  extracted.  (Wm.  T.  Ball, 
quoted  by  Solis-Cohen,  '  Annual  of  the  Universal  Medical  Sciences,'  1888, 
vol.  iii.  p.  328.) 

Case  XXV. — Impaction  of  false  teeth  in  the  oesophagus  :  successfid 
removal  through  the  stomach  by  the  aid  of  gastrotoTny. 
A  man  aged  37  swallowed  his  false  teeth  while  eating.  A  small 
ivory  probang  detected  the  body  easily,  situated  far  down,  apparently  near 
the  stomach.  Every  method  at  removal  failing,  the  man  readily  con- 
sented to  the  proposed  operation.  After  opening  the  abdomen,  an  incision 
an  inch  and  a  half  long  was  made  into  the  stomach.  Through  this  opening 
an  endeavour  was  made  with  instruments  to  extract,  but  failing,  the  incision 
was  enlarged,  and  the  hand  and  forearm  inserted  into  the  stomach.  The 
middle  and  index  fingers  were  then  passed  up  the  oesophagus  between  the 
heart  in  front  and  the  aorta  behind,  till  the  body  was  felt  and  its  bearing 
ascertained.  A  little  careful  manipulation  with  the  index  finger  loosened 
the  body,  and  it  then  easily  came  away.  The  patient  made  an  excellent 
recovery.  (Maurice  H.  Eichardson,  '  Boston  Medical  and  Surgical 
Journal,'  1886,  vol.  cxv.  p.  567.  See  similar  treatment  in  a  case  of 
Finney,  '  Annals  of  Surgery,'  1893,  vol.  xvii.  p.  228.) 


CHAPTER   IV 

INFLAMMATORY  AFFECTIONS  OF  THE  (ESOPHAGUS  :  ACUTE  TRAU- 
MATIC CESOPHAGITIS  ;  ACUTE  IDIOPATHIC  OESOPHAGITIS  ; 
OESOPHAGITIS  OF  CHILDREN;  MEMBRANOUS  OR  PELLICULAR 
OESOPHAGITIS  ;  APHTHOUS  CESOPHAGITIS  ;  CHRONIC  CESOPHA- 
GITIS ;  PHLEGMONOUS  OESOPHAGITIS  ;  SUBMUCOUS  OESOPHAGEAL 
ABSCESSES  ;  CATARRHAL  CESOPHAGITIS  ;  FOLLICULAR  OESOPHA- 
GITIS ;    CROUPOUS    OESOPHAGITIS 

Arising  from  whatever  cause,  oesophagitis  is  a  comparatively 
rare  disease.  It  is  most  commonly  met  with  as  an  involve- 
ment of  inflammation  of  the  pharynx  or  stomach.  What- 
ever may  be  the  general  symptoms  present  in  these  cases, 


INFLAMMATORY   xiFFECTIOXS  37 

those  connected  directly  with  disease  of  this  particular  part 
are  as  a  rule  more  or  less  masked  by  the  symptoms  arising 
from  the  affection  of  the  other  regions.  Treatment,  therefore, 
has  reference  often  rather  to  these  latter  than  to  the  former. 
Again,  it  maybe  said  that  inflammatory  affections  of  the  oeso- 
phagus will  more  frequently  fall  to  the  hand  of  the  physician 
for  treatment  than  the  surgeon.  Occasionally,  however,  either 
as  an  immediate  result  of  the  inflammation  or  as  an  after 
effect,  symptoms  may  arise  calling  for  surgical  treatment.  I 
propose  therefore  to  refer  briefly  to  these  various  inflammatory 
conditions.  It  is  doubtful  how  far  one  is  right  in  speaking  of 
these  different  affections  as  various  forms  of  inflammation.  It 
is  quite  possible,  and  indeed  probable,  that  differences  are  due 
more  to  the  degree  or  intensity  of  the  inflammation  than  to 
its  kind.  This  view  has  been  strongly  advanced  by  Jonathan 
Hutchinson,^  and  it  would  seem  more  than  likely  that  the 
cause  of  the  disease  determines  the  intensity  of  the  inflamma- 
tion, rather  than  any  special  pecuharity  in  its  manifestation. 
Any  one  cause  may  induce  either  a  slight  or  a  severe  attack, 
and  the  appearances  and  symptoms  will  correspondingly  vary. 

Acute  traumatic  oesophagitis. — Acute  inflammation  as  the 
result  of  injury  is  the  form  most  commonly  met  with.  It  may 
arise  as  the  result  of  mechanical  injury,  as  in  the  impaction  of 
a  foreign  body  ;  as  the  consequence  of  a  sting  of  an  insect,  as 
in  the  case  of  a  wasp  accidentally  swallowed  ;  or,  as  is  most 
commonly  the  case,  as  the  result  of  swallowing  some  powerful 
irritant. 

Symptoms. — In  the  case  of  the  imbibition  of  caustics  or 
corrosives,  it  very  commonly  happens  that  the  symptoms 
arising  from  the  injury  to  the  parts  above  and  below  mask 
those  which  would  otherwise  indicate  involvement  of  the 
gullet ;  but  when  sufficiently  pronounced  to  assert  themselves, 
they  will  be  found  to  consist  mostly  in  a  burning  sensation  felt 
down  the  neck  and  in  the  chest,  pain  to  a  variable  extent, 
tenderness  on  palpation  of  the  gullet,  and  more  or  less  pain 
at  any  endeavour  to  swallow.  In  the  case  of  stings  of  insects, 
or  impacted  foreign  bodies,  the  inflammation  may  be  of  a  more 
local  character.     Pain  may  be  referred  to  a  particular  point 

'  Brit.  Med.  Journ.  1892,  vol.  ii.  p.  881. 


38  THE   (ESOPHAGUS 

either  behind  or  in  front,  above  or  below,  according  to  the 
locality  of  the  mischief,  and  it  may  be  similarly  localised  in  any 
attempt  at  swallowing. 

Case  XXVI. — Acute  oesophagitis  the  result  of  the  sting  of  a  wasp. 
Recovery  in  nine  days. 

A  gentleman  aged  54  swallowed  a  wasp,  in  the  act  of  drinking  some 
beer.  He  suddenly  felt  a  very  sharp  pain  at  the  epistemal  notch. 
Severe  paroxysms  of  coughing  took  place,  followed  by  vomiting.  "When 
seen  about  three  hours  after  the  accident,  he  was  very  anxious  and  faint, 
and  complained  of  something  in  his  throat,  just  above  the  sternum.  He 
was  unable  to  swallow.  A  subcxitaneous  injection  of  morphia  was  given, 
and  later  in  the  day  the  patient  was  much  relieved,  although  still  unable 
to  swallow.  On  the  following  day  he  was  able  to  swallow  fluids,  but  not 
until  nine  daj's  after  the  accident  was  he  able  to  swallow  solids.  (Morell 
Mackenzie,  vol.  ii.  p.  45.) 

Prognosis. — The  cases  of  stings  of  insects  reported  are 
too  few  to  admit  of  any  certain  statement.  It  is  probable, 
however,  that  the  effect  of  a  sting  will  vary  in  the  oesophagus, 
just  as  much  as  it  does  when  the  skin  is  the  seat  of  the  lesion. 
Since  in  the  latter  it  is  rarely  of  any  moment,  it  may  be 
assumed  that  no  serious  result  will  ensue  when  the  gullet 
is  attacked.  As  regards  oesophagitis  due  to  the  other 
traumatic  causes  named,  the  danger  lies  not  so  much  in  the 
acute  condition  of  the  part  itself  at  the  time  as  in  the  after 
effects.  If  the  acute  inflammation  leads  to  ulceration,  then 
all  the  troubles  connected  with  a  traumatic  stricture  of  the 
canal  must  be  expected. 

Treatment. — Little  or  nothing  can  be  done  as  regards  the 
part  itself.  Eest  being  the  object  required,  nutrition  should 
be  effected  as  long  as  possible  by  nutrient  enemata.  A  little 
ice  may  be  given  to  relieve  any  dry  or  parched  feeling  of  the 
mouth.  Any  pain  or  anxiety  may  be  overcome  by  subcutaneous 
injections  of  morphia. 

Acute  idiopathic  oesophagitis. — To  the  late  Sir  Morell 
Mackenzie  belongs  the  credit  in  this  country  of  drawing  atten- 
tion to  a  well-defined,  though  apparently  excessively  rare,  form 
of  oesophagitis.  In  his  work — '  Diseases  of  the  Throat  and  Nose,' 
vol.  ii. — will  be  found  an  exhaustive  description  of  the  disease  ; 
and  such  brief  notice  as  space  will  permit  here,  I  must  acknow- 
ledge as  abstracted  from  his  account.  Prior  to  his  work,  it 
would  seem  that  every  case  recorded  had  come  from  abroad  ; 


INFLAMMATORY  AFFECTIONS  39 

he  was  himself,  however,  enabled  to  record  five  cases  that  he 
had  seen  and  treated.  In  looking  up  the  literature  of  the 
subject  since  1884,  the  date  of  his  work,  I  fail  to  find  any  record 
of  cases  in  this  country,  and  only  one  from  abroad  (Schech). 
This  disease  therefore  must  either  be  very  rare  or,  as  believed 
by  Mackenzie,  frequently  not  recognised.  As  regards  the  cause 
of  the  affection,  nothing  of  any  constant  or  definite  character 
seems  ascertainable.  In  Mackenzie's  five  cases,  one  appears 
to  have  arisen  after  taking  several  ices ;  a  second  to  have 
been  the  result  of  alcoholic  abuse ;  a  third  to  have  followed 
accidental  immersion  in  a  river ;  and  the  remaining  to  have 
occurred  in  rheumatic  patients. 

Symptoms. — One  of  the  most  marked  symptoms  is  pain  in 
the  act  of  deglutition,  which  is  frequently  of  a  severe  burning 
or  tearing  character.  Pain  of  a  dull  aching  kind  is  also  often 
felt  deep  in  the  neck  and  chest.  Tenderness  is  complained  of 
on  external  palpation  of  the  cesophagus  ;  and  any  movement 
of  the  neck,  or  even  the  movement  involved  in  speaking,  some- 
times augments  the  patient's  suffering.  Feverish  symptoms 
exist.  The  patient  complains  of  dryness  of  the  mouth  and 
thirst,  notwithstanding  the  constant  expectoration  of  frothy 
mucus.  Delirium  is  sometimes  present.  Should  the  inflam- 
mation proceed  to  ulceration,  the  expectoration  may  become 
tinged  with  blood.  The  formation  of  an  abscess  may  be 
indicated  by  rigors  and  the  augmentation  of  the  patient's 
symptoms. 

Diagnosis. — While  the  extreme  difficulty  and  pain  in  swallow- 
ing will  prove  positive  factors  in  localising  the  disease,  the 
absence  of  certain  other  symptoms  will  more  largely  assist  in 
determining  the  diagnosis.  Thus,  the  exclusion  of  any  mischief 
connected  with  the  pharynx  or  the  air  passages  ;  the  absence 
of  symptoms  suggestive  of  hydrophobia,  as  general  hyper- 
esthesia, paroxysms  of  asphyxia,  and  mental  aberration ;  the 
non-existence  of  pericarditis,  which  either  through  pain  or 
pressure  might  mislead. 

Prognosis. — In  most  cases  the  prognosis  appears  to  have 
been  favourable.  In  Mackenzie's  five  cases  all  did  well. 
Ulceration  may  take  place  and  abscess  may  form.  Gangrene 
also  has  occurred,  but  it  must  be  considered  an  extremely 
rare  sequel. 


40  THE   (ESOPHAGUS 

Treatment. — Little  further  need  be  stated  than  has  ah'eady 
been  said  in  the  treatment  of  acute  traumatic  oesophagitis. 
Warm  fomentations  will,  when  applied  to  the  neck,  sometimes 
afford  relief.  Placing  the  feet  in  hot  water  may  be  tried  with 
advantage.  Belladonna  plasters  applied  to  the  back,  or  the 
liniment  rubbed  into  the  skin,  will  relieve  pain.  In  four  out 
of  Mackenzie's  five  patients  subcutaneous  injections  of  mor- 
phia were  administered  with  good  effect. 

Case  XXVII. — Acute  idiopathic  oesophagitis. 
H.  E.,  aged  23,  had  been  upset  from  a  boat  into  the  water,  and  remained 
in  for  some  time  before  he  was  taken  out.  He  was  insensible  for  about  half 
an  hour  after  being  brought  to  shore.  On  the  next  day  he  was  feverish, 
and  in  the  afternoon  felt  difiiculty  in  swallowing.  Later,  in  attempting  to 
swallow  some  soup  it  was  violently  ejected.  He  was  slightly  delirious 
during  the  night,  and  frequently  expectorated  saUva.  The  third  day,  when 
first  seen,  he  was  spitting  up  large  quantities  of  ropy  mucus.  Slight 
inflammation  was  seen  to  exist  at  the  lower  part  of  the  pharynx  and  the 
epiglottis,  but  both  larynx  and  trachea  were  normal.  Great  pain  was  felt 
in  attempting  to  swallow  a  little  water.  On  the  fourth  day  improvement 
set  in,  and  at  the  end  of  a  week  from  the  commenceiment  of  his  illness  he 
was  practically  well.  The  treatment  consisted  in  subcutaneous  injections 
of  morphia.     (Morell  Mackenzie,  vol.  ii.  p.  34.) 

(Esophagitis  of  children. — The  form  of  oesophagitis  here 
referred  to  occurs  in  children  usually  under  two  years  of  age, 
and  most  frequently  within  the  earlier  months  of  infantile  life. 
The  disease  appears  to  have  first  attracted  the  attention  of 
Billard,  who  in  his  work  '  On  Diseases  of  Infants  '  devotes 
considerable  space  to  the  discussion  of  the  subject.  Mackenzie 
also  has  a  couple  of  pages  dealing  with  the  disease ;  and 
Brush,  of  New  York,  has  contributed  a  paper  seeking  to  attract 
further  notice  to  this  otherwise  but  little  recognised  affection.^ 

The  cause  of  the  complaint,  so  far  as  ascertained,  appears 
to  be  bad  feeding.  Infants  have  been  fed  on  artificial  food, 
such  as  '  sweetened  gum-water  and  milk  and  water '  given 
too  hot,  or  the  mother  or  nurse  has  sore  nipples  or  a  defective 
quality  of  milk. 

Symptoms. — Brush  gives  as  the  first  and  foremost  sym- 
ptom, '  an  antipathy  to  food,  and  when  food  is  taken  lachry- 
mation  takes  place.'  Upon  this  latter  symptom  he  lays  great 
stress,    deeming   it   almost   pathognomonic.      Further,    any 

'  Neio  York  Medical  Record,  1883,  vol.  xxiii.  p.  35. 


INFLAMMATORY   AFFECTIONS  41 

attempt  to  swallow  being  accompanied  with  pain,  the  child 
cries  and  ceases  to  suck  ;  and  any  food  which  may  have  been 
swallowed  is  promptly  thrown  up,  frequently  before  it  has 
had  time  to  reach  the  stomach.  Pressure  on  the  oesophagus 
through  the  neck  may  cause  pain.  The  child  frequently 
suffers  from  diarrhoea,  and  is  in  all  general  respects  very  ill. 
Sometimes  collapse  becomes  a  prominent  feature,  at  other 
times  convulsions. 

Diagnosis. — The  condition  is  not  one  always  easy  of  dia- 
gnosis. The  rapid  vomiting  after  deglutition  may  suggest 
some  congenital  malformation  of  the  canal,  or  some  cerebral 
mischief ;  and  the  diarrhoea,  which  is  a  frequent  accompani- 
ment, may  indicate  gastro-intestinal  disturbance.  In  vomit- 
ing, however,  the  result  of  malformation,  '  all  the  milk  is 
ejected,  and  paroxysms  of  suffocation  are  brought  on  by 
attempts  to  swallow  '  (Mackenzie).  Again,  in  vomiting  due  to 
gastric  disturbances  the  act  is  usually  accompanied  with 
nausea,  and  in  vomiting  due  to  cerebral  irritation  the  food 
is  not  so  powerfully  ejected  (Bruce). 

Prognosis  — Judging  from  the  cases  reported  by  Billard 
and  Bruce,  the  disease  appears  a  very  fatal  one,  causing 
death  either  by  inanition,  or  more  directly  through  the 
disease  itself.  Cases  of  Condie  quoted  by  Bruce,  however, 
present  a  more  favourable  aspect  of  the  disease,  as  all  the 
former's  cases  recovered.  In  one  of  Bruce's  cases  perforation 
of  the  oesophagus  took  place,  and  in  one  of  Billard's  gangrene 
of  the  canal. 

Treatment. — No  endeavour  should  be  made  to  force  the 
child  to  take  fluid  by  the  mouth.  The  treatment  of  Condie's, 
which  seems  to  have  been  fraught  with  uniform  success,  was 
to  give  injections  per  rectum  of  milk  and  broth.  This  should 
be  done  every  three  hours.  The  child's  neck  should  be 
wrapped  round  with  warm  fomentations.  Before  attempting 
to  resume  administration  by  the  mouth,  attention  should  be 
directed  to  the  mother's  nipples,  or  if  the  child  has  been 
artificially  fed,  to  the  food  and  the  mechanical  means  used 
for  its  administration. 

Case  XXVIII. —  (Esophagitis  in  a  child. 
H.  T.,   aged    6   j'ears,  when   first   seen    on    July    11,  presented  the 
following  symptoms  :  general   pallor,    slight  distension  of   the  abdomen. 


42  THE  (ESOPHAGUS 

with  feeble  but  unmistakable  cry ;  vomiting  its  food.  On  the  15th  the 
face  had  become  livid.  The  child  refused  to  drink,  or  drank  but  little  ; 
cried  when  any  forcible  endeavour  was  made  to  feed  it.  It  vomited  with- 
out any  effort  and  almost  immediately  after  swallowing  any  milk ;  diar- 
rhoea, which  existed  at  the  first,  continued.  From  the  liith  to  17th 
the  symptoms  continued;  the  pallor  increased,  and  emaciation  became 
marked.  On  the  18th  the  face  appeared  shrivelled-looking,  the  forehead 
was  furrowed  with  wrinkles,  the  cry  very  feeble,  the  skin  cold,  and  the 
pulse  almost  imperceptible.  In  the  night  the  child  died.  Post  mortem  : 
the  oesophagus  was  acutely  injected  in  its  upper  third,  the  epithelium 
being  also  totally  destroyed.  The  lower  two-thirds  presented  several 
reddish  striations.  The  stomach  and  intestines  presented  the  appearance 
of  chronic  gastro-enteritis.     (Billard, '  Traite  des  Enfants,'  p.  292.) 

Although  this  case  is  quoted  as  an  example  of  the  disease, 
and  given  as  such  by  Billard,  it  must  be  confessed  that  the 
extensive  involvement  of  the  stomach  and  intestines  would 
in  all  probability  explain  many  of  the  symptoms.  Had 
indeed  the  oesophagus  not  been  examined  at  the  post  mortem, 
it  is  not  improbable  that  what  was  found  elsewhere  would 
have  been  accepted  as  sufficient  to  have  accounted  for  the 
symptoms  during  life  and  the  death  of  the  child. 

Membranous  or  pellicular  cesophagitis. — The  formation  of  a 
membrane  within  the  oesophagus  may  be  due  to  diphtheria, 
the  swallowing  of  boiling  water,  or  other  more  obscure  causes. 
In  the  case  of  diphtheria  the  membrane  is  usually  an  exten- 
sion from  the  pharynx,  the  disease  is  of  a  severe  and  extensive 
type,  and  any  oesophageal  symptoms  are  usually  masked  by 
those  arising  from  the  involvement  of  other  parts.  As  a  rule 
the  existence  of  a  diphtheritic  membrane  in  the  oesophagus 
may  be  said  to  be  a  purely  post-mortem  revelation.  Few,  if 
any,  authenticated  cases  are  on  record  of  recovery.  A  case 
recently  published  by  Fry  of  Washington  is  a  good  illustration 
of  the  disease  and  its  course. 

Case  XXIX. — Diphtheritic  oesox>hagitis. 
Miss  P.,  aged  18,  when  first  seen  was  sitting  up  in  bed  spitting 
blood  freely.  On  examination,  the  right  tonsil  was  found  to  be  the  source 
of  the  bleeding,  and  upon  this  and  the  opposite  tonsil  were  patches  of 
diphtheritic  membrane.  For  some  three  or  four  days  the  patches  on  the 
tonsils,  though  removed  in  order  to  give  relief,  always  re-formed.  Her 
pulse  ranged  from  120  to  140,  and  her  temperatures  from  104"  to  105°. 
She  suffered  both  from  repeated  attacks  of  epistaxis  and  haemorrhage 
from  the  tonsil.     Her  breath  was  extremely  offensive.     Her  menstrual 


INFLAMMATOHY   AFFECTIONS  43 

flow,  which  had  now  lasted  for  twelve  days,  had  changed  to  a  sero-san- 
guineous  discharge  and  contained  pieces  of  diphtheritic  membrane.  On 
the  fifth  day  her  restlessness  reached  a  climax  when,  by  combined  retch- 
ing and  hawking,  she  spat  up  a  long  cast  of  membrane.  The  following 
day  a  similar  cast  a  little  less  than  nine  inches  in  length  was  again  ejected, 
alter  a  fit  of  choking.  From  this  period  she  gradually  sank,  and  died  of 
exhaustion.  (H.  D.  Fry,  '  American  Journal  of  the  Medical  Sciences,' 
1885,  N.S.  vol.  xc.  p.  329.) 

The  paper  by  Fry  from  -whicli  the  above  case  is  abstracted 
will  be  found  to  contain  about  all  that  is  known  of  this  disease. 
It  should  be  consulted  for  further  information. 

With  regard  to  membranes  or  pellicles  which  form  in  the 
oesophagus  as  the  result  of  drinking  boiling  water,  Wilks  and 
Moxon  '  mention  having  seen  two  such  cases.  It  would  appear 
that  cases  arising  from  this  cause  are  of  little  more  than 
pathological  interest,  for  death  usually  results  from  the  injury 
simultaneously  inflicted  upon  the  fauces  and  larynx. 

An  interesting  case  has  been  reported  by  von  Eeichman  ^ 
of  a  man  aged  83  who  for  more  than  ten  years  had 
suffered  from  difficulty  in  swallowing.  When  attempting  to 
swallow  a  piece  of  meat  it  suddenly  became  impacted.  On 
expulsion,  a  mass  of  membrane  about  one  hundred  cubic 
centimeters  in  bulk  was  ejected.  Difficulty  in  deglutition  still 
persisted,  but  the  passage  of  a  bougie  easily  overcame  the 
obstruction.  A  few  days  later  some  membrane  was  passed 
with  the  faeces,  and  other  portions  were  vomited.  The 
membrane  was  found  to  be  '  composed  of  multiple  layers  of 
squamous  and  strongly  cornified  epithelium.'  A  somewhat 
similar  case  is  quoted  by  Fry  in  the  paper  above  alluded  to. 
The  case  is  recorded  by  Mathias  Jacobseus.  *  A  man  had 
difficulty  in  swallowing  for  two  years  and  a  half.  He  could 
get  no  relief  until  he  passed  by  stool  a  false  membrane  that 
came  from  the  oesophagus.'  Pietkiewicz,^  of  Baku,  reports  a 
case  of  a  cast  being  ejected  from  the  oesophagus  eleven  days 
after  swallowing  a  teaspoonful  of  a  twenty-five  per  cent,  solu- 
tion of  caustic  soda.  Severe  pain  was  felt  about  the  throat 
and  breast,  and  increasing  difficulty  in  deglutition.  The  throat 
was  painted  with  glycerine  solution  of  tannin  with  cocaine. 

'  PatJiological  Anatomy,  2nd  edit.  p.  365. 

^  Solis-Cohen,  Annual  of  the   Universal  Medical  Sciences,  1891,  vol.  iv. 
F— 31.  3  Brit.  Med.  Journ.  Epitome,  1894,  vol.  ii.  p.  33. 


44  THE   (ESOPHAGUS 

After  a  second  painting  he  coughed  up  a  '  bowel,'  when  deght- 
tition  became  quite  easy.  The  '  bowel '  proved  to  be  the  mucous 
membrane  of  the  oesophagus,  detached  as  a  whole  in  the  form 
of  a  cylinder  twenty-two  centimeters  long,  from  two  and  a  half 
to  three  and  a  half  broad,  and  from  one  to  two  millimeters 
in  thickness.  The  case  is  described  as  one  of  '  oesophagitis 
gangrenosa.' 

Aphthous  oesophagitis. — As  an  affection  of  itself  thrush  of 
the  oesophagus  rarely,  if  ever,  occurs.  "When  the  gullet  is 
attacked  it  is  almost  always  in  association  with  a  similar  con- 
dition of  the  mouth  or  pharynx,  more  frequently  the  combina- 
tion is  with  the  mouth  and  the  oesophagus.  The  diagnosis 
of  involvement  of  the  gullet  depends  almost  entirely  upon  the 
difficulty  of  swallowing,  occasionally  accompanied  with  vomit- 
ing. The  disease  usually  attacks  infants,  and  but  rarely  leads 
to  a  fatal  issue.  A  somewhat  unique  case  is  recorded  by 
Langenhaus,^  where  the  aphthae  in  the  oesophagus  had  led 
to  a  purulent  inflammation  of  the  mucous  membrane.  Except 
that  the  patient  stated  a  few  days  before  death  that  he  had 
lost  the  power  of  tasting  his  food  properly,  no  symptoms 
existed  indicative  of  this  part  of  his  trouble.  The  condition 
was  revealed  post  mortem. 

Chronic  oesophagitis. — Although  a  rare  .affection,  chronic 
inflammation  of  the  oesophagus  is  occasionally  met  with.  It 
is  usually  the  result  of  some  prolonged  irritation  of  the  lining 
membrane  of  the  canal,  either  from  continuous  and  frequent 
indulgence  in  ardent  spirits  or  a  similar  habit  of  taking  foods 
too  hot  or  too  irritant.  It  is  said  also  to  follow  upon  some 
traumatic  abrasion  of  the  wall,  and  as  a  sequel  to  acute 
oesophagitis.  A  certain  degree  of  inflammation  is  co-existent 
with  syphilitic  ulceration  and  carcinoma,  and  is  the  result 
not  unfrequently  of  some  organic  obstruction.  It  is,  however, 
as  an  unassociated  disease  that  it  is  dealt  with  here. 

Symptoms.— The  inflammation  being  slow  in  its  progress, 
the  symptoms  are  insidious,  and  at  first  somewhat  obscure. 
Later,  however,  dysphagia  manifests  itself,  accompanied  fre- 
quently with  pain,  at  an  early  stage,  only  when  swallowing 
solids,  but  later  when  taking  fluids.  As  in  the  acute  form  of 
the  disease,  there  is  an  increase  in  the  expectoration  of  frothy 

'  Virchow's  Archiv,  1887,  Bd.  cix.  p.  352. 


INFLAMMATORY   AFFECTIONS  4/5 

mucus,  only  to  a  much  less  extent.  In  any  attempt  at 
deglutition,  auscultation  of  the  oesophagus  may  reveal  a  de- 
layed progress  of  the  bolus  downwards,  accompanied  with  '  a 
loud  harsh  noise  if  the  surface  of  the  mucous  membrane  be 
roughened  '  (Mackenzie).  The  existence  of  the  dysphagia  may 
lead  the  surgeon  to  pass  a  bougie,  when  it  will  be  found  to  be 
obstructed  in  its  course.  Such  instrumentation,  however, 
should  be  avoided  if  possible,  especially  where  the  symptoms 
are  sufficiently  clear  to  indicate  the  true  nature  of  the  affection. 
The  passage  of  a  bougie  only  tends  to  further  irritate  the 
mucous  membrane,  give  pain,  and  often  cause  some  bleeding. 

Diagnosis. — The  disease  may  be  mistaken  for  spasm  of  the 
oesophagus ;  for  some  laryngeal  disease  ;  or  for  commencing 
carcinoma.  In  the  case  of  spasm  of  the  oesophagus  the  affec- 
tion is  transitory,  the  difficulty  of  deglutition  being  both 
sudden  in  its  onset  and  in  its  disappearance.  From  laryngeal 
disease  about  the  orifice  of  the  larynx  giving  rise  to  dysphagia, 
the  laryngoscope  will  show  the  absence  of  any  inflammatory 
mischief  in  these  parts.  While  from  carcinoma  the  age  of  the 
patient  may  lend  some  assistance ,-'  but  the  subsequent  course 
of  malignant  disease  will  soon  exclude  any  possible  mistake. 

Prognosis. — With  proper  treatment  these  cases  rapidly 
improve  and  get  well ;  but  recurrence  is  frequent. 

Treatment. — The  cause  being  some  irritant,  the  treat- 
ment consists,  in  the  first  place,  in  removing  such  source  of 
irritation,  and  keeping  the  part  as  much  as  possible  at  rest. 
This  is  best  accomplished  by  a  careful  regimen,  by  which  every- 
thing of  an  irritant  nature  is  forbidden,  while  simple  bland 
foods  are  alone  permitted.  Internal  administrations  are  of 
little  good.  If  pain  exists  it  may  be  relieved  by  the  applica- 
tion of  a  blister,  a  mustard  poultice,  or  a  hot  fomentation. 
Hypodermic  injections  of  morphia  may  also  be  resorted  to. 

Case  XXX. — Chronic  oesoijhagitis. 
C.  S.,  a  biatcher,  aged  47,  when  first  seen  was  suffering  from  dysphagia 
and  pain  over  the  episternal  notch.  He  had  been  a  di'inker,  and  had 
noticed  latterly  a  slightly  increased  flow  of  saliva.  Auscultation  of  the 
cesophagiis  revealed  great  slowness  of  deglutition.  A  bougie  was  passed, 
but  would  not  descend  beyond  the  upper  third.  It  caused  him  pain  and 
some  bleeding.  He  was  ordered  milk  and  beef  tea.  A  week  later  he  was 
beginning  to  improve,  and  in  a  few  days  more  the  pain  in  his  neck  had 
decreased,  and  he  was  able  to  take  some  bread  and  milk.     At  the  end  of 


46  THE   (ESOPHAGUS 

two  and  a  half  months  he  had  quite  recovered.  He  had  been  advised  to 
give  up  alcohol,  and  also  to  discontinue  his  custom  of  crying  out  the  price 
of  his  goods  to  attract  his  customers.  About  two  years  after  he  had  a 
second  attack,  but  this  was  much  milder,  and  passed  off  in  three  weeks. 
(Morell  Mackenzie,  vol.  ii.  p.  50.) 

Phleg^monous  oesophagitis  and  Submucous  oesophageal 
abscesses. — Under  the  heading  of  Phlegmon  of  the  (Esophagus, 
Puech  ^  reports  the  case  of  a  man  who  swallowed  a  table- 
spoonful  of  a  solution  of  caustic  potash  and  soda.  At  the  end 
of  eight  days  he  vomited  a  long  tubular  cast  in  two  portions, 
one  measuring  twenty-four  centimeters  in  length,  and  the 
other,  triangular  in  shape  from  the  mucous  membrane  of  the 
stomach,  measuring  twenty-two  millimeters.  The  man  died, 
but  no  autopsy  was  made.  The  author  believes  that  a  veritable 
phlegmon  was  produced.  It  may  be  a  question  whether,  as  a 
matter  of  classification,  this  case  should  not  occur  as  illustra- 
tive of  what  has  been  described  as  membranous  oesophagitis. 
In  many,  if  not  in  all  respects,  it  resembles  the  cases  included 
under  that  heading. 

The  conditions  in  this  class  of  oesophageal  inflammation 
are,  however,  of  little  clinical  significance,  and  have  an  in- 
terest more  for  the  pathologist  than  the  surgeon.  I  merely 
mention  them  to  complete  the  list  of  the  various  inflammatory 
affections  to  which  the  oesophagus  is  subject.  To  this  end 
must  also  be  mentioned  Catarrhal  and  Follicular  oesophagitis, 
both  affections  which  have  been  described  as  attacking  solely 
the  mucous  membrane.  Croupous  oesophagitis  consists  in  an 
infiltration  of  the  submucous  and  muscular  coats  with  pus, 
while  the  mucous  membrane  remains  intact.  A  case  of  this 
nature  is  recorded  by  Dionisi.^ 


CHAPTER  V 

ULCER.       VAEICOSE    VEINS.       SYPHILIS.       TUBERCULOSIS 

Ulcer. — Several  cases  of  simple  ulcer  of  the  oesophagus  have 
now  been  recorded,  and  no  doubt  can  longer  be  entertained  of 
the  occasional  occurrence  of  an  ulcer  in  this  region  similar  in 

'  Joal,  Journal  of  Laryngology  and  Rhinology,  1891,  vol.  v.  p.  116. 
-  Urit.  Med.  Journ.  Epitome,  1896,  vol.  ii.  p.  9. 


ULCER 


47 


all  respects  to  that  more  commonly  met  with  m  the  stomach 
(see  fig.  6).  Many  of  our  leading  pathologists  '  record  in  their 
works  unequivocal  examples  of  this  form  of  ulcer.  Finlay- 
son  ^  related  to  the  Glasgow  Pathological  and  CHnical  Society 
an  interesting  case  which  came 
under  his  observation,  and  re- 
ferred to  others  of  a  like  nature. 
Ulceration  may  occur  in  the 
course  of  the  affections  already 
described,  for  instance,  as  a 
sequel  to  the  impaction  of  a 
foreign  body,  or  in  the  course  of 
some  acute  imflammatory  affec- 
tion of  the  canal.  Stricture 
resulting  from  any  cause  gives 
rise  to  ulceration  of  that  part  of 
the  gullet  immediately  above  the 
obstruction.  Sypiiilis,  malignant 
disease,  tuberculosis,  and  many 
of  the  acute  exanthemata  attack- 
ing any  part  of  the  canal  may  lead 
to  ulceration.  A  form  of  ulcera- 
tion arising  from  gastric  solution 
and  leading  to  rupture  has  been 
previously  referred  to  (see  page 
15). 

Symptoms. — The  occurrence  of  ulceration  can  often  only  be 
suspected,  and  in  some  cases  it  is  not  until  perforation  takes 
place  that  suspicion  is  aroused.  Again,  it  may  be  said  that 
the  existence  of  ulceration  is  more  frequently  a  post-mortem 
revelation  than  a  clinical  observation.  Thus  in  a  specimen 
exhibited  by  Pitt  at  the  London  Pathological  Society,^  '  two 
similar  flat  oval  patches  of  ulceration  with  their  long  dia- 
meter longitudinal,  about  |  inch  by  ^  inch,  were  found  in  the 
oesophagus  in  process  of  healing.'  The  child  died  rapidly  from 
an  acute  attack  of  diphtheria,  but  had  previously  never  shown 

'  See  Coats,  Manual  of  Pathology,  3rd  edit.  p.  830  ;  also  Wilks  and  Moxon, 
Pathological  Anatomy,  2nd  edit.  p.  366. 

-  Glasgoio  Med.  Journ.  1883,  vol.  xix.  No.  4,  p.  313. 
^  Society's  Trans.  1888,  vol.  xxxix.  p.  107. 


Fig.  6.  —  Simple  Peefoeating 
Ulcee  of  the  (Esophagus.  The 
Main  Beonchus  of  the  Left 
Lung  was  penetrated.     (Coats) 


48  THE   a<]SOPHAGUS 

any  signs  of  ulceration  of  the  gullet.  Where  there  are  diseases 
existing  in  which  it  is  known  that  ulceration  may  take  place, 
the  appearance  of  blood  in  the  sputum  and  the  localisation  of 
pain  in  some  particular  spot  during  deglutition  may  lead  to  a 
correct  diagnosis.  In  the  case  of  an  ulcer  involving  the  lower 
end  of  the  oesophagus  reported  by  Keher,^  the  symptoms  were 
so  strongly  suggestive  of  the  disease  being  in  the  stomach  that 
it  was  not  till  the  post-mortem  examination  was  made  that 
the  real  seat  of  the  ulcer  was  found. 

Prognosis. — Ulcers  occurring  and  progressing,  from  what- 
ever cause,  may  lead  to  perforation.  Such  perforations  are 
more  frequent  in  carcinoma  of  the  oesophagus ;  these  will  be 
more  extensively  referred  to  under  the  discussion  of  that  disease. 
The  simple  ulcer  corresponding  to  that  found  in  the  stomach 
may  lead  to  perforation.  In  the  case  recorded  by  Coats,  the 
bronchus  was  opened  into.  As  to  the  results  which  may  accrue 
from  the  healing  of  an  ulcer,  these  will  depend  upon  the 
depth  and  superficial  extent  to  which  ulceration  has  taken 
place.  Where  there  has  been  much  destruction  of  the  wall  there 
will  be  a  correspondingly  larger  formation  of  cicatricial  tissue, 
and  this  must  lead  to  narrowing  of  the  calibre  of  the  canal. 

Case  XXXI. — Slviple  tdcer  of  the  cesojyhag^ts  leading  to  stricture. 

A  man  aged  55  came  under  observation  on  June  29,  1885.  The 
history  of  his  case  was  that  in  1869,  while  in  the  enjoyment  of  good 
health,  he  was  seized,  on  the  same  day,  with  two  severe  attacks  of  haema- 
temesis.  This  greatly  enfeebled  him,  and  he  was  compelled  to  keep  his 
bed  for  a  fortnight.  He  then  got  up  and  went  about  his  usual  work.  For 
ten  years  he  kept  well,  when  in  1879  he  had  a  fresh  attack  of  hsematemesis. 
This  was  succeeded  in  1882  by  a  third  return  of  bleeding,  which  lasted  for 
four  days.  At  ths  time  a  bougie  was  passed  without  any  indication  of 
obstruction.  He  again  recovered  completely,  and  then,  nine  months  later, 
began  for  the  first  time  to  feel  pain  in  the  region  of  the  epigastrum  and 
posteriorly  on  a  level  with  the  eighth  dorsal  vertebra.  He  tried  himself 
to  pass  a  bougie,  but  found  it  was  obstructed.  Deglutition  now  also  com- 
menced to  trouble  him,  and  increased  so  as  to  render  even  the  passage  of 
fluids  almost  impossible.  The  diagnosis  being  made  of  contraction  following 
a  simple  ulcer  of  the  oesophagus,  forcible  dilatation  with  bougies  was  prac- 
tised, with  the  ultmiate  complete  relief  of  the  patient.-  (M.  Debove, '  Gazette 
Hebdomadaire  de  Med.  et  de  Chir.'  1885,  2"  serie,  tome  xxii.  p.  676.) 


'  Deutsches  Archiv  fur  Klin.  Med.  1885,  Bd.  xxxvi.  p.  454. 
2  The  correctness  of  the  diagnosis  was  verified  at  a  post-mortem  examination 
of  the  patient  held  two  years  later.     See  Stenosis  following  Simple  Ulcer. 


ULCER.      VARICO^^E   VEINS  49 

Treatment. — An  ulcer  in  the  oesopbagus  must  be  treated 
on  the  same  broad  principles  which  characterise  the  treat- 
ment of  ulcers  in  the  stomach  and  elsewhere.  Eest  alone 
is  needed,  and  if  for  any  purpose  it  is  necessary  to  pass  a 
bougie  or  a  tube,  this  must  be  done  with  great  care.  As  long 
as  it  is  possible  to  keep  up  thepatient's  strength  by  nutrient 
enemata,  nothing  except  a  little  ice,  or  a  little  bland  fluid  of 
some  kind,  should  be  given  by  the  mouth.  It  is  not  merely 
the  passage  of  substances  over  the  surface  of  the  ulcer  which 
must  be  considered,  but  the  disturbing  effect  of  the  muscular 
contraction  caused  by  deglutition. 

Varicose  veins. — The  existence  of  varix  or  phlebectasis  in 
the  cBSophagus  is  not  an  infrequent  occurrence.  Thus  Morell 
Mackenzie,'  in  the  examination  of  eighteen  gullets  taken  at 
random,  found  more  or  less  dilatation  in  seven  and  distinct 
varix  in  two.  Frequent,  however,  as  would  seem  to  be  the  exis- 
tence of  some  degree  of  this  condition,  it  is  rarely  that  symp- 
toms indicative  of  it  arise.  It  has  recently  been  shown  by  C.  A. 
Blume,^  of  Copenhagen,  who  injected  the  oesophageal  vessels, 
that  the  submucous  veins  empty  into  the  coronary  vein  of  the 
stomach,  while  the  perioesophageal  veins  communicate  with  the 
diaphragmatic  and  azygos  veins.  Obstruction  therefore  occur- 
ring in  the  liver,  as  from  cirrhosis  or  senile  atrophy,  gives  rise 
to  a  dilatation  of  the  submucous  veins  ;  and  these  being  con- 
nected with  the  perioesophageal,  an  increased  vascular  con- 
nection is  formed  between  the  portal  vein  and  the  vena  cava. 
Such  increased  connection  between  these  two  large  veins  is  said 
to  retard  for  a  time  the  progress  of  ascites  in  cases  of  cirrhosis, 
but  the  dilatation  of  the  veins  so  occasioned  renders  them 
liable  to  rupture,  and  thus  to  become  the  cause  of  haemate- 
mesis.  Varices  as  a  cause  of  hsematemesis  in  cirrhosis  of  the 
liver  has  been  made  the  subject  of  an  exhaustive  paper  by 
J.  Stacy  Wilson  and  J.  E.  Eatcliffe,^  who  incorporate  several 
cases  illustrative  of  the  condition. 

It  is  possible  that  in  some  instances  the  varicose  condition  of 
the  veins  may  be  congenital.    Such  seems  the  only  explanation 

'  Vol.  ii.  p.  54. 

^  Solis-Cohen,  Annual   of  tlie   Universal  Medical  Sciences,  1889,  vol.  iv. 
G-36. 

3  Brit.  Med.  Journ.  1890,  vol.  ii.  p.  1480. 

E 


50  THE   CESOPHAGUS 

in  a  case  recorded  by  Friedricb.'  A  cbild  aged  6  years  bad 
for  two  years  suffered  from  repeated  bsemorrhage,  from  wbicb 
it  died.  It  was  at  first  thought  that  the  blood  came  from  the 
stomach,  but  at  the  post  mortem  the  oesophagus  was  found 
filled  with  thick  varicose  veins. 

The  position  of  the  affected  veins  may  be  above,  beJow,  or 
at  any  intermediate  place.  In  obstructive  disease  of  the 
liver  they  appear  more  frequently  at  the  lower  end  ;  while  in 
old  age,  wben  varices  are  prone  to  form  in  various  regions,  they 
are  found  more  at  the  upper  part. 

Symptoms  and  diagnosis. — The  recorded  instances  of  un- 
complicated cases  of  varix  are  far  too  few  to  admit  of  any 
special  symptoms  being  stated  that  might  be  termed  patho- 
gnomonic of  the  complaint.  When  haemorrhage  results  from 
varix,  in  which  the  latter  condition  is  dependent  upon  some 
ol)structive  influence  working  on  the  portal  circulation  through 
the  liver,  it  is  all  but  impossible  to  say  whether  the  blood  is 
from  the  stomach  or  the  gullet.  Blume  affirms  that  when  the 
haemorrhage  is  due  to  a  rupture  of  the  varicose  veins,  the  blood 
is  ordinarily  expelled  by  a  sort  of  regurgitation  without  vomit- 
ing. In  cases  of  varix  occurring  at  the  middle  and  upper 
part  of  the  oesophagus,  Mackenzie  asserts  the  possibility  of 
establishing  a  diagnosis  by  means  of  the  oesophagoscope,  and 
in  one  of  his  own  recorded  cases  he  was  enabled  to  do  so.  In 
the  absence  of  any  other  symptoms  suggestive  of  disease  of 
the  liver,  the  cause  of  the  hsemorrhage  might  be  suspected  to 
be  in  the  oesophagus.  Here  again,  however,  as  in  the  case 
below  recorded,  the  diagnosis  would  more  likely  be  that  of 
gastric  ulcer,  and  it  would  be  difficult  to  distinguish  between 
the  two  complaints.  The  heemorrhage  from  a  ruptured  vein 
may  be  sufficiently  copious  to  cause  death,  as  in  a  case  reported 
by  Viti.2 

Treatment. — Where  there  is  reason  to  suspect  that  blood 
is  coming  from  varicose  veins  of  the  oesophagus,  the  treatment 
will  be  in  all  respects  such  as  would  be  adopted  in  the  case  of 
gastric  ulcer.  Cold  may  be  applied  externally  either  to  the 
sternum  and  epigastrum  or  to  the  back.     Ice  may  be  sucked, 

'  Joiirnal  of  Laryngology  and  Ehinology,  1895,  vol.  ix.  p.  284. 
-  Brit.  Med.  Journ.  Epitome,  1890,  vol.  ii.  p.  C-5. 


VARICOSE   VEINS  ;5l 

or  astringents  may  be  administered.  Zenker  '  advises  tincture 
of  the  percliloride  of  iron  in  doses  of  5  to  10  drops.  Mackenzie  '^ 
l)rescribes  a  mixture  of  tannic  and  gallic  acids.  Nutrient 
enemata  should  take  the  place  of  food  by  the  mouth  so  long 
as  the  tendency  to  haemorrhage  exists ;  but  when  bleeding 
seems  to  have  ceased,  iced  milk  may  be  given,  and  a  milk 
diet  maintained  for  some  time. 

Case  XXXII. —  Varix  of  the  oesojphagws.  Death  from  lice  mar  rliage. 
A  man  aged  40  had  been  ill  for  twelve  years.  He  dated  his  illness  from 
an  attack  of  typhoid  fever  which  occurred  at  the  beginning  of  that  time. 
He  was  in  bed  for  seventeen  weeks,  and  his  life  at  one  time  despaired  of. 
He  had  adopted  several  means  to  recoup  his  strength.  Four  years  ago  he 
first  vomited  blood,  and  during  the  last  year  he  had  eight  times  brought  up 
blood.  He  was  subject  to  bilious  attacks,  as  appears  were  also  his  mother, 
brothers  and  sisters.  Sometimes  he  suffered  from  heartburn,  and  some- 
times felt  shar]D  pains  in  the  region  of  the  stomach.  His  bowels  were  con- 
stipated, and  occasionally  the  stools  contained  blood.  He  suffered  from 
haemorrhoids.  On  May  12,  fi-om  no  error  in  diet,  he  vomited  some  dark  red 
coagulated  blood.  There  was  tenderness  in  the  pit  of  his  stomach  ;  and 
succussion  of  the  patient  gave  rise  to  evident  fluctuation  in  the  region  of 
the  stomach.  His  tongue  was  fissured,  moderately  pale,  and  yellowish 
postei'iorly.  All  his  other  organs  appeared  healthy.  Ulcer  of  the 
stomach  was  diagnosed.  Vomiting  of  blood  continued  on  May  18 
and  19,  when  the  patient  died.  At  the  post  morteioi  extensive  varicosity 
of  the  veins  was  found  at  the  lower  part  of  the  oesophagus,  with  a 
well-marked  rent  in  one  of  the  veins  ;  with  the  exception  of  a  fatty  heart, 
there  was  no  evidence  of  disease  elsewhere.  (Eberth,  '  Deutsches  Archiv 
fill-  lOui.  Med.'  1880,  vol.  xxvii.  p.  566.) 

Case  XXXIII. — Fatal  licBmorrkage  from  varicose  oesophageal  veins. 
The  patient  was  a  man  aged  60,  who  had  had  syphilis  when  about  25,  and 
had  drunk  to  excess  since  about  his  twentieth  year.  In  1890  he  suddenly 
vomited  about  two  pints  of  blood.  He  was  repeatedly  tapped  for  extreme 
ascites.  He  suddenly  brought  up  several  puits  of  pure  blood  and  passed 
some  with  the  stools,  and  died  on  the  following  day,  apparently  from 
exhaustion.  The  liver  was  found  to  be  contracted  and  much  altered 
in  shape.  The  veins  in  the  lower  part  of  the  oesophagus  were  greatly 
enlarged,  and  there  was  a  distinct  opening  in  one,  leaving  no  doubt  as  to 
the  source  of  the  hgemorrhage.  The  stomach  appeared  to  be  normal. 
(EdcUson,  '  Brit.  Med.  Journ.'  1893,  vol.  i.  p.  239.)  See  also  another  case 
reported  by  Letuille  and  abstracted  by  Joal,  in  '  Journal  of  Laryngology 
and  Ehinology,'  1891,  vol.  v.  p.  116. 

'  CyclopcBcUa  of  the  Practice  of  Medicine,  vol.  viii.  p.  133. 
2  Vol.  ii.  p.  55. 

E  2 


52  THE   CESOPPIAGUS 

Syphilis. — The  ]ining  membrane  of  the  oesophagus,  like  the 
skin  and  mucous  membrane  elsewhere,  is  liable  to  be  attacked 
by  some  form  of  syphilitic  inflammation.  This  is,  however,  a  rare 
complication  of  both  the  hereditary  and  acquired  forms  of  the 
disease.  Pathologically  considered,  the  lesion  is  mostly  some 
form  of  ulceration,  either  superficial  where  the  mucous  mem- 
brane is  firpt  involved,  or  deep  where  the  primary  source  has 
been  a  gumma.  The  result  in  both  cases  is  the  same ;  healing 
usually  takes  place,  and  the  cicatrix  formed  may  or  may  not 
give  rise  to  stricture  of  the  canal  according  to  the  depth  and 
extent  of  the  original  lesion.  Syphilis  is  sometimes  the  cause 
of  oesophageal  paralysis ;  but  in  such  cases  the  lesion  is 
primarily  connected  with  the  nervous  system,  and  the  gullet 
thus  secondarily  involved. 

Symptoms. — The  chief  symptom  is  that  of  dysphagia, 
comparatively  slight  at  first,  but  gradually  increasing  as  the 
canal  becomes  narrowed.  During  the  active  stages  of  ulcera- 
tion some  slight  haemorrhage  may  exist  and  localised  pain  be 
complained  of.  The  various  symptoms  arising  from  stricture 
due  to  this  disease  will  be  more  fully  discussed  in  the 
chapter  dealing  with  cicatricial  stenosis. 

Diagnosis. — There  will  be  little  difficulty  in  deciding  that 
the  symptoms  of  obstruction  are  due  to  some  organic  lesion, 
but  it  will  not  be  so  easy  to  determine  whether  or  not  the 
existing  cause  is  syphilis.  There  is  nothing  special  in  the 
symptoms  to  distinguish  them  from  those  dependent  upon 
ulceration  or  stricture  due  to  other  causes,  and  the  diagnosis 
— almost  always  conjectural— must  be  based  on  the  existence 
or  pre-existence  of  syphilitic  manifestations  elsewhere. 

Treatment. — The  usual  specific  remedies  will  be  called  for, 
especially  iodide  of  potassium ;  for  the  disease,  when  it  comes 
under  treatment,  is  usually  in  its  later  or  tertiary  stage  than 
in  the  earlier.  In  addition  nourishment  must  be  administered 
on  the  principle  of  giving  rest  to  the  part,  and  on  the  general 
lines  before  laid  down  in  all  cases  of  ulceration.  The  treat- 
ment of  stricture  will  be  dealt  with  later. 

Tuberculosis. — There  is  little  to  be  said  about  this 
disease.  As  a  primary  affection  there  appear  to  be  no  really 
authenticated  recorded  instances.  The  oesophagus  is  some- 
times secondarily  involved  in  tubercular  processes  taking  place 


TUlJEKCULUSiS  68 

elsewhere.  Many  references  to  such  eases  are  given  by 
Mackenzie,'  but  the  larger  proportion  of  these  are  doubtful. 
Zenker  and  Ziemssen  '^  mention  having  seen  two  cases  which 
they  thought  might  possibly  be  illustrations  of  the  affection. 
Several  other  cases  also  are  referred  to  in  a  paper  by  Weich- 
selbaum/'  who  bases  his  remarks  upon  a  case  which  came 
under  his  observation.  Zemann ''  has  met  with  some  cases,  and 
instances  four  ways  in  which  the  OBsophagus  may  be  implicated. 
The  most  frequent  method  of  involvement  is  by  extension  from 
a  tuberculous  gland,  which  gradually  eats  its  way  into  the 
oesophagus  and  so  infects  it.  Another  mode  of  invasion  is 
directly  from  the  larynx.  A  third  source  of  infection  arises 
from  inoculation  of  a  part  of  the  canal — previously  injured 
by  swallowing  some  caustic  fluid — by  swallowing  tubercular 
sputum  in  cases  of  pulmonary  phthisis.  A  fourth  kind  of  in- 
volvement is  where  the  disease  of  the  oesophagus  is  a  part  of  a 
general  miliary  tuberculosis ;  and  he  quotes,  in  illustration  of 
this  last,  Mazotti's  case  of  a  boy  aged  10  who  had  also  acute 
tubercular  meningitis.  Flexner  •''  more  recently  has  reported  a 
case  somewhat  similar  to  Mazotti's,  inasmuch  as  the  tubercular 
ulcers  found  in  the  oesophagus  were  part  of  a  general  tubercu- 
losis. Bacilli  were  found  in  these  ulcers.  Konrad  Zenker  ^ 
records  two  instances  of  infection  of  the  oesophagus,  from 
primary  disease  in  the  lungs  in  one  case,  and  tubercular 
mediastinal  glands  in  the  other.  In  both  the  gullet  was  per- 
forated. Weichselbaum's  case  appears  to  be  an  unequivocal 
illustration  of  the  disease.  Not  only  were  the  lesions  strongly 
suggestive  of  tuberculosis  to  the  naked  eye,  but,  as  in  Flexner 's 
case,  the  existence  of  the  tubercle  bacillus  was  demonstrated. 
During  life  the  patient  presented  no  symptoms  indicative  of 
involvement  of  the  oesophagus.  She  had  tuberculous  caseating 
glands  in  the  neck,  which  had  been  opened.  Her  death  sub- 
sequently took  place  from  pulmonary  phthisis,  although  she 
had  no  symptoms  of  this  disease  when  first  seen.  At  the 
post  mortem  the    oesophageal  mischief  was   discovered,    and 

>  Vol.  ii.  p.  112. 

-  Cyclopadia  of  Medicine,  vol.  viii.  p.  191. 

^  Wiener  Mcdizinische  Wochenschrift,  1884,  vol.  xxxiv.  p.  151. 

*  Ibid.  1886,  No.  49,  p.  1646. 

*  Brit.  Med.  Journ.  Epitome,  1893,  vol.  i.  p.  60. 

^  Deutsches  Archiv  filr  Klin.  Med.  1895,  Bel.  Iv.  p.  422. 


64  THE   (ESOPHAGUS 

around  the  organ  in  its  thoracic  part  numerous  caseating 
and  suppurating  glands  existed.  Weichselbaum  expresses 
his  behef  that  the  infection  of  the  oesophagus  was  due  to  a 
perforation  of  the  canal  by  a  tuberculous  gland. 

The  disease  cannot  be  said  to  have  any  special  surgical 
interest,  and  indeed  its  existence  as  yet  has  been  little  else  than 
a  pathological  curiosity.  Why  the  oesophagus  should  be  so 
exempt  from  infection  it  is  not  easy  to  say,  unless  it  be,  as 
suggested  by  Weichselbaum,  that  the  virus,  -which  may  attack 
other  parts  of  the  alimentary  canal,  passes  too  rapidly  down 
the  oesophagus  to  seize  upon  its  walls. 


CHAPTEE   VI 

TUMOURS  :  INNOCENT PAPILLOMA.       CYSTS.       FIBROMA.       ADENOMA. 

MYXOMA.       MYOMA.       LIPOMA 

Various  kinds  of  benign  tumours,  as  pathologically  understood, 
have  from  time  to  time  been  found  attached  to  the  inner  wall 
of  the  oesophagus.  Occurring,  however,  in  whatever  form,  they 
are  but  rarely  met  with,  and  still  more  rarely  diagnosed. 
Although  innocent  structurally,  they  have  in  some  cases,  from 
the  special  nature  of  the  region  attacked,  given  rise  to  severe 
symptoms,  ending  fatally.  It  would  seem,  however,  that  in 
not  a  few  cases  there  are  no  symptoms  at  all,  and  quite 
accidentally  tumours  have  been  discovered  after  death.  As 
in  malignant  tumours,  these  benign  growths  are  found  more 
frequently  in  men  than  in  women,  and  for  this  reason  it  has 
been  assumed  that  irritation,  caused  mostly  through  the  con- 
sumption of  alcohol,  is  the  exciting  cause  of  some  topical 
development. 

The  benign  growths  which  have  been  found  in  the  oesophagus 
are  warts  or  papillomata,  cysts,  fibromata,  adenomata,  m^-xo- 
mata,  and  myomata.  Some  authors  add  also  lipomata  ; 
but  while  instances  are  recorded  illustrative  of  each  of  the 
former  growths,  there  appears  no  authentic  reference  to  a  case 
of  the  latter. 

Warts  or  Papillomata.  —These  growths  appear  to  be  hyper- 
trophied    papillse   of   the   mucous   membrane,    covered   with 


INNOCENT   TUMOURS  .55 

additional  layers  of  epithelium.  They  may  be  said  to  i-osoml)le 
warts  on  the  skin,  and,  like  them,  may  be  simple  or  multiple. 
They  may  exist  in  any  part  of  the  canal,  and  are  sometimes 
sprinkled  over  its  entire  length.  They  are  found  usually  in 
elderly  people,  and  are  unaccompanied  by  any  special  sym- 
ptoms. A  typical  example  of  these  tumours  was  shown  by 
Sharkey  '  to  the  Pathological  Society  of  London.  It  was  taken 
from  a  man  aged  67  years  who  died  of  chronic  bron- 
chitis. The  mucous  membrane  of  the  oesoiDhagus  was  thickly 
studded  with  tumours,  varying  in  size  from  a  pin's  head  to  a 
pea. 

Cysts. — In  most  cases  these  are  simple  retention  cj^sts 
arising  in  connection  with  the  mucous  follicles.  When  of  such 
a  nature  they  are  not  usually  large,  rarely  exceeding  in  size  a 
pea,  and  do  not  number  more  than  one  or  two.  They  contain 
viscid  mucus.  Instances  of  much  larger  cysts  than  these 
have  been  recorded.  Fagge^  showed  a  specimen,  at  the 
Pathological  Society  of  London,  of  a  cyst  as  large  as  a  pigeon's 
egg.  It  was  filled  with  viscid  mucus,  and  projected  consider- 
ably into  the  oesophagus.  Whether  the  patient  had  suffered 
from,  dysphagia  was  not  ascertained.  Wyss^  records  an 
example  of  a  still  larger  cyst.  It  was  about  the  size  of  an 
apple,  and,  as  far  as  was  known,  had  not  given  rise  to  trouble 
during  life. 

Fibromata,  Adenomata,  Myxomata,  and  Myomata. — These 
growths  constitute  relatively  the  most  frequently  met  with 
forms  of  benign  tumours.  They  usually  occur  as  polypi 
attached  by  a  distinct  neck  or  constricted  base  to  any  part 
of  the  wall  of  the  gullet,  although  the  region  of  the  cricoid 
cartilage  is  perhaps  the  most  usual  spot.  In  size  they  vary 
considerably,  being  as  a  rule  much  greater  in  length  than 
breadth.  When  attached  by  an  elongated  pedicle  they  may 
occasionally  present  at  the  back  of  the  throat,  or  even  project 
into  the  mouth.  In  a  case  reported  by  Annandale  *  the 
polypus  measured  four  inches  in  length,  an  inch  and  a  half 
in  breadth,  with  a  pedicle  about  the  size  of  a  lead  pencil  and 

'  The  Society's  Transactions,  1885,  vol.  xxxvi.  p.  189. 

-  Ibid.  1875,  vol.  xxvi.  j).  96. 

^  Virehow's  Archiv,  1870,  Bd.  li.  p.  144. 

■'  Brit.  Med.  Journ.  1878,  vol.  ii.  p.  761. 


56  THE  CESOPHAGUS 

two  inches  long.  In  any  fit  of  retching  or  coughing  the 
polypus  came  out  of  the  patient's  throat  on  to  his  tongue. 
In  another  case,  reported  by  James, ^  a  polypus  about  the  size 
of  a  pea  and  pear-shaped  used  to  appear  in  the  patient's 
mouth  just  behind  the  tongue.  On  attempting  to  extract  it, 
it  burst,  and  a  little  glairy  fluid  escaped.  A  case  of  ordinary 
mucous  polypus  is  recorded  by  Cheatham.^  It  was  five 
inches  in  length  and- one  inch  in  diameter,  and  in  vomiting 
was  projected  into  the  mouth.  Ziemssen  ^  quotes  a  case  of 
Eokitansky's  which  appears  to  be  one  of  the  largest  speci- 
mens of  fibrous  polypus  recorded.  It  measured  seven  and  a 
half  inches  in  length  and,  at  its  blunt  end,  which  was  situated 
two  and  a  half  inches  above  the  cardia,  two  and  a  half  inches 
in  thickness. 

As  illustrations  of  myomata  are  the  cases  repeatedly 
quoted  of  Coats  ^  and  Hilton  Fagge.^  In  the  case  reported  by 
the  former,  a  lobulated  tumour  measuring  four  and  three- 
quarter  inches  from  above  downward,  two  inches  in  a  trans- 
verse diameter  and  about  an  inch  and  a  quarter  in  the  other 
diameter,  was  found  extending  from  a  point  about  six  and 
three-quarter  inches  below  the  level  of  the  glottis  downwards  to 
the  cardiac  orifice  of  the  stomach.  The  tumour  was  removed 
post  mortem  from  a  man  aged  61  years.  In  Fagge's  case 
the  tumour  grew  from  the  anterior  wall  of  the  gullet,  just 
below  the  bifurcation  of  the  trachea.  It  was  egg-shaped,  and 
its  long  axis,  which  lay  obliquely,  measured  two  inches,  its 
other  axes  being  respectively  one  inch  and  a  quarter  and  one 
inch . 

Symptoms. — With  so  few  cases  to  deal  with,  and  with  such 
inconstancy  in  the  symptoms  presented,  it  is  not  possible  to 
indicate  any  features  which  may  be  said  to  be  generally 
characteristic  of  polypus  of  the  gullet.  Dysphagia,  which 
would  naturally  be  the  most  likely  symptom  to  exist,  is  often 
absent,  and  that  too  in  some  of  the  most  marked  cases.  Thus 
in  Annandale's  case  the  patient  never  suffered  either  from 

'  Brit.  Med.  Journ.  1878,  vol.  ii.  p.  832. 

^  Solis-Cohen,  Annual  of  the   Universal  Medical  Sciences,  1892,  vol.  iv. 
F — 30.  ^  Cyclopcedia,  vol.  viii.  p.  171. 

^  Glasgow  Med.  Journ.  1871-72,  N.S.  vol.iv.  p.  201. 
^  Trans.  Path.  Soc.  Lond.  1875,  vol.  xxvi.  p.  94. 


INNOCENT  TUMOURS  57 

trouble  in  swallowing  or  difficulty  in  breathing.  Likewise  in 
Fagge's  case  there  was  no  dysphagia,  and  in  that  of  Coats's 
dysphagia  appeared  only  ten  weeks  before  death.  In  Eoki- 
tansky's  case,  where  the  polypus  was  the  largest  on  record,  dys- 
phagia was  only  suffered  from  a  few  months  before  the  patient's 
decease,  and  then  only  lasted  for  a  short  time.  On  the  other 
hand,  where  the  polypus  was  no  larger  than  a  pea,  as  in 
James's  case,  the  woman  suffered  from  dysphagia  for  a  year, 
and  when  first  seen  she  could  hardly  swallow  anything.  In 
the  first  of  Mackenzie's  three  recorded  cases  '  the  polypus  was 
about  the  size  of  a  marble,  and  difficulty  in  swallowing  had 
been  experienced  for  eleven  months.  The  dysphagia  increased 
until  only  liquid  nourishment  could  be  taken.  In  other  cases, 
again,  there  have  been  prolonged  symptoms  of  difficulty  in 
swallowing,  with  periods  of  intermission,  when  food  could  be 
taken  with  moderate  ease  ;  the  existence  of  such  intermittency 
might  reasonably  suggest  the  presence  of  some  benign  ob- 
structing growth.  In  the  third  of  Mackenzie's  cases  sym- 
ptoms of  dysphagia  had  existed  more  or  less  for  six  or  seven 
years.  When  the  polypus  moves  freely  by  a  long  pedicle,  it 
may,  by  coughing  or  retching,  be  brought  up  to  the  back  of 
the  throat  or  into  the  mouth,  as  instanced  in  the  cases 
above. 

Case  XXXIV. — Polypus  of  the  cesopliagus. 

A  man  aged  47  years  consulted  Sir  Morell  Mackenzie  in  June  1875  on 
accoulit  of  difficulty  in  swallowing.  This  symptom  was  first  noticed  two 
and  a  half  years  previously  after  eating  some  fish,  and  the  patient  attri- 
buted the  trouble  to  the  lodgment  of  a  bone.  The  difficulty  in  swallowing 
had  increased  by  slow  but  not  regular  degrees.  At  first  it  was  slight  and 
only  came  on  occasionally,  whilst  at  other  times  the  food  went  down  jjer- 
fectly  well.  During  the  first  six  months  of  1874  the  dysphagia  passed  off, 
but  in  the  beginning  of  July  of  that  year  it  suddenly  returned.  At  the 
patient's  urgent  solicitation  a  parasol  bougie  was  passed.  It  went  down 
easily,  but  in  withdrawing  it  some  difficulty  was  experienced,  when  sud- 
denly the  obstruction  yielded,  and  a  small  pedunculated  tumour  about  the 
size  of  a  bantam's  egg  fell  from  the  patient's  mouth.  He  subsequently 
brought  up  about  a  teacupful  of  blood.  With  only  this  symptom  and  a 
little  pain  in  swallowing  for  a  few  days,  he  ultimately  quite  recovered. 
(Morell  Mackenzie, '  Diseases  of  the  Throat  and  Nose,'  vol.  ii.  jp.  104,  case  2.) 

Treatment. — The  removal  of  the  polypus  is  the  only 
object  aimed    at,  and  this  has  been  effected  in  some  cases 

'  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  101. 


68  THE   (ESOPHAGUS 

accidentally,  and  in  others  by  similar  simple  methods  to  those 
used  in  the  case  of  nasal  polypi.  In  two  of  Mackenzie's  cases 
the  polypus  was  removed  accidentally  during  the  process  of 
examination  of  the  patient  by  the  passage  of  a  parasol  bougie  : 
on  withdrawing  the  bougie  a  hitch  was  felt,  which  suddenly  gave 
way,  and  the  tumour  was  brought  up.  In  Annandale's  case  the 
tumour  was  caught  by  forceps  and  its  base  encircled  with  an 
ecraseur.  Stephan  rather  ingeniously  induced  vomiting  by  the 
hypodermic  injection  of  a  sixth  of  a  grain  of  apomorphia, 
which  caused  the  tumour  to  be  thrown  into  the  mouth,  when 
it  was  caught  with  a  vulsellum  forceps,  surrounded  with  a  wire 
snare  and  cut  off  close  to  its  base.  In  whatever  way  removed, 
a  little  haemorrhage  usually  follows  the  detachment  of  the 
growth,  but  this  soon  subsides,  and  after  a  few  days  of  painful 
deglutition,  variable  in  degree,  the  patient  makes  a  complete 
recovery. 


CHAPTEE   VII 

TUMOURS  :    MALIGNANT CARCINOMA   AND    SARCOMA 

Carcinoma. — Etiology. — The  oesophagus,  like  other  portions 
of  the  alimentary  canal,  is  liable  to  be  attacked  by  carcinoma. 
Anatomically  it  is  made  of  the  same  tissues,  in  which  the 
disease  is  prone  to  arise ;  and  physiologically  it  is  subject  to 
the  same  exciting  causes.  Whatever  part  irritation  may  take 
in  initiating  the  malignant  process,  it  can  hardly  be  deemed 
so  cogent  a  factor  in  the  appearance  of  the  disease  as  might 
be,  and  is  usually,  supposed.  The  comparative  rarity  of 
carcinoma  of  the  cesophagus,  and  the  universal  frequency  with 
which  that  canal  must  be  accidentally  irritated  by  the  occa- 
sional deglutition  of  hot  fluids,  excess  of  stimulants,  insuffi- 
ciently masticated  food,  &c.,  renders  it  more  than  likely  that 
some  other  factor,  more  potent  than  that  of  irritation,  must 
be  looked  for  in  many  cases.  Whether  that  factor  is  to  be 
found  in  a  simple  predisposition  of  the  tissues — and  this  sup- 
position is  strongly  supported  by  the  greater  frequency  of  the 
disease  in  members  of  a  family  where  it  has  already  shown 
itself  in  some  form — or  in  some  phase  connected  with  the  new 
development  of  the  parasitic  theory  must  remain  for  future 


CAKCINOMA  69 

decision.  The  subject,  however,  is  one  touching  the  general 
pathology  of  carcinoma ;  while  here  we  have  to  deal  with  this 
disease  as  a  local  affection,  attacking  a  particular  region. 
However  the  affection  may  arise,  it  is  usual,  with  our  present 
knowledge,  to  ascribe  it  to  a  predisposition  of  the  tissues, 
incited  to  undergo  these  special  changes  by  some  mechanical 
injury  to  the  particular  part. 

Statistics  leave  little  doubt  that  the  disease  is  far  more 
frequent  in  men  than  in  women  ;  thus  in  100  cases  collected 
by  Morell  Mackenzie  '  the  disease  was  found  71  times  in  men 
and  29  in  women.  The  age  at  which  it  most  frequently 
appears  is  from  50  to  60  years.  The  decades  immediately 
before  and  after  this  show  an  equal  frequency,  and  in  both 
cases  but  slightly  numerically  less.  Before  20  years  and  after 
80  years  the  oesophagus  is  rarely  affected. 

Pathology. — No  portion  of  the  oesophagus  is  exempt  from 
invasion.  From  its  commencement  to  its  termination  carci- 
noma has  attacked  any  region,  and  any  part  of  that  region. 
Various  portions  of  the  tract  have  been  signalled  out  as  more 
frequently  involved  than  others,  but  the  want  of  uniformit^^  in 
the  results  obtained  by  different  statisticians  renders  it  almost 
impossible  to  indicate  one  part  more  than  another  as  being 
specially  prone  to  the  disease.  Butlin  ^  is  probably  right  in 
giving  the  central  portion  of  the  canal  as  that  least  often 
affected. 

From  the  nature  of  the  circumstances,  as  regards  the  sea 
of  the  disease,  and  its  insidious  onset,  it  is  not  possible  to 
know  what  are  the  first  pathological  manifestations  of  the 
growth.  It  can  only  be  assumed  that  its  origin  will  be  much 
the  same  as  where  carcinoma  arises  on  some  visible  surface. 
Thus  it  may  commence  as  a  small  papilloma  or  warty  groAvth, 
as  a  surface  plaque  or  a  deeper-seated  induration,  as  a  fissure, 
abrasion,  or  slight  ulceration  ;  but  in  whatever  way  the  disease 
first  manifests  itself,  sooner  or  later  growth  and  ulceration 
become  the  prominent  pathological  processes,  and  we  finally 
have  all  those  later  appearances  with  which  we  are  familiar 
in  the  post-mortem  room. 

It  must  be  remembered  that  in  dealing  with  carcinoma, 

'  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  75. 
-  Operative  Surgery  of  Malignant  Disease,  p.  207. 


60  THE   (ESOPHAGUS 

wherever  it  is  found,  three  pathological  processes  are  at  work  : 
growth,  destruction,  and  contraction.  The  growth  as  seen  in  the 
region  under  discussion  manifests  itself  at  the  advancing  part 
of  the  disease  -  that  is  to  say,  it  forms  prominent  edges  to  the 
ulcerating  surface,  and  indurates  the  neighbouring  tissues  by 
infiltration.  Destruction  is  seen  towards  the  central  part  of 
the  disease,  where  the  process  may  either  be  molecular  disin- 
tegration or  the  separation  of  large  sloughs.  This  process  in 
its  progress  rapidly  leads  to  the  destruction  of  parts  beyond 
that  of  the  region  attacked.  Thus  the  oesophagus  is  perforated 
and  any  neighbouring  cavity  or  structure  opened  into.  The 
process  of  contraction  consists  in  the  development  of  fibrous 
tissue  both  within  and  without  the  tumour  tissue  proper. 
The  shrinking  of  the  fibrous  stroma  of  the  growth,  as  also  of 
that  developed  as  the  result  of  inflammatory  irritation,  gives 
rise  to  the  narrowing  of  the  canal ;  and  this,  together  with  the 
projecting  masses  of  the  growth,  cause  all  those  symptoms  of 
obstruction  which  form  the  striking  features  and  characteristics 
of  the  disease. 

The  macroscopical  appearances  of  the  diseased  part  when 
seen  on  the  post-mortem  table  are  extremely  various.  A 
typical  example  will  be  that  of  a  mass  of  growth  completely 
encircling  the  canal  for  a  variable  extent  upwards  and  down- 
wards, and  reducing  its  calibre  to  a  minimum.  Ulceration 
will  also  be  found  to  a  greater  or  less  extent.  While  then  it 
may  be  said  to  be  the  rule  to  find  a  limited  circumferential 
contraction  and  ulceration,  numerous  cases  occur  where  the 
disease  is  both  more  limited  and  more  extensive.  Thus  the 
disease  may  extensively  invade  the  wall  of  the  canal  and  yet 
not  diminish  its  calibre,  as  in  a  case  recorded  by  Hoden  ;  ^ 
somewhat  similar  cases  are  also  recorded  by  Newman  ^  and  by 
Page.^  The  growth  may  form  a  mere  localised  projection  into 
the  canal  ;  at  other  times  specimens  are  met  with  where 
more  than  one  spot  seems  to  be  separately  afl'ected.  In  many 
of  these  there  is  direct  lymphatic  connection,  the  disease 
travelling  along  the  lymphatic  channels  and  then  developing 
as   apparently  isolated   centres.       Page's   case  ^   apparently 

'  New  York  Medical  Record,  1888,  vol.  xxxiii.  p.  719. 

2  New  York  Med.  Journ.  1879,  vol.  xxx.  p.  158. 

3  Medical  Press  and  Circular,  1892,  vol.  i.  p.  il'6. 


PLATE    111. 


^^iXi^Rw^H^^^n 

■  jk 

V^K^ 

i 

n^Kpl 

j 

|n^K'> 

^H^-'^^^ 

i 

Kw^HRv 

^^ft  i  iH^HI 

f     dA 

^-jti^BOfc,;; 

^^K    IK^^I 

\Sk 

iffljp 

Eil^flB 

iil:  i^        '^ 

iJP 

Qi 

r^n^^r^  ^«^.   vijf  ^   .' 

■pi^Bj 

K 

^m  \fi 

AT 

^ln 

H 

^^ 

Fig.  7.— Carcinoma  of  CEsophagus.— A  flat  fungating  tumour  occupies  about  the 
lower  4^  inches  of  the  gullet.  The  mass  ends  abruptly  above,  but  below 
presses  down  against  the  wall  of  the  stomach,  but  the  latter  is  not  involved. 
The  ring  of  whalebone,  seen  below,  Indicates  the  cardiac  orifice;  and  the 
piece  above  a  small  perforation  which  lead  to  gangrene  of  the  lung. 
(IV.I.M.,  Glas.) 


CArvCTNOMA  (51 

illustrates  this  method  of  extension.  The  chief  seat  of  the 
disease  was  opposite  the  bifurcation  of  the  trachea  ;  at  the 
cardiac  extremity  of  the  stomach  w.as  a  similar  growth.  Be- 
tween the  growths  the  mucous  membrane  on  the  summit  of 
the  rugae  contained  numerous  areas  of  carcinoma  which 
varied  in  size  from  a  mere  point  to  a  small  bean,  and  were 
mostly  linear  in  shape  and  direction.  In  some  cases  the 
disease  extends  from  the  oesophagus  directly  by  continuity 
into  the  stomach,  as  in  a  case  recorded  by  Burnet/  the 
cardiac  end  and  the  lesser  curvature  being  involved  ;  or  the 
stomach  may  be  infected,  with  no  obvious  connection  between 
the  two  centres  of  disease.  Thus  in  a  case  recorded  by 
Hadden''^  a  small  nodule  of  growth  was  found  in  the  mucous 
membrane  of  the  stomach  just  beyond  the  cardiac  orifice,  the 
main  centre  of  the  disease  being  located  in  the  upper  part  of 
the  cesophagus.  Specimens  from  a  similar  case  were  shown 
to  the  Montreal  Medico-Chirurgical  Society  by  Wyatt.^  At 
the  autopsy  two  epitheliomata  were  found  high  up  in  the 
OBSophagus  ;  whilst  within  the  stomach,  near  the  oesophageal 
opening,  was  another  tumour.  How  extensive  may  be  the 
invasion  of  the  disease  is  well  illustrated  by  a  case  recorded  by 
Finny.''  The  region  affected  commenced  opposite  the  arch  of 
the  aorta,  and  from  that  spot  to  within  a  quarter  of  an  inch 
of  the  stomach  the  canal  was  one  mass  of  disease  of  a  most 
extensive  nature.  A  more  severe  case'^  than  this  even  is 
illustrated  by  a  specimen  in  Guy's  Hospital  Museum  '  where 
nearly  the  whole  length  of  the  tube  is  occupied  by  the  disease 
in  its  sloughing  stage.'  Besides  the  various  appearances 
presented  by  the  seat  of  the  disease  itself,  the  oesophagus  both 
above  and  below,  especially  above,  undergoes  changes,  as  the 
result  mostly  of  the  obstruction  in  its  canal.  Thus  above  the 
seat  of  disease  the  walls  of  the  gullet  may  become  thickened 
from  muscular  hypertrophy,  and  the  whole  calibre  of  the 
canal  may  be  dilated  (see  Plate  V.  fig.  9).  In  a  case  reported 
by  Eoosevelt,*^  where  the  disease  was  situated  near  the  cardiac 

'  Trans.  Path.  Soc.  Loncl.  1881,  vol.  xxxiii.  p.  191. 

*  Brit.  Med.  Journ.  1891,  vol.  ii.  p.  1097. 

'  Journal  of  Laryngology  and  Rhinology,  1891,  vol.  v.  p.  327. 

■•  Dublin  Journal  of  the  Medical  Sciences,  1882,  3rd  series,  vol.  Ixxiv.  p.  1G7. 

*  Pathological  Anatomy,  Wilks  and  Moxon,  2nd  edit.  p.  3G6. 
«  Nciu  York  Med.  Journ.  1887,  vol.  xlv.  p.  500. 


62  THE   (ESOPHAGUS 

orifice  and  tlie  calibre,  so  small  that  only  a  probe  could  be 
passed,  the  dilatation  extended  up  to  near  the  thyroid  cartilage, 
and  converted  the  oesophagus  into  a  cavity  about  the  size  of  a 
'  champagne  bottle.'  Such  an  extensive  dilatation  in  malig- 
nant disease  is  uncommon — although  the  author  expressly 
points  out  that  in  his  case  the  obstruction  was  of  a  malignant 
nature.  The  complaint  usually  runs  a  too  rapid  course,  and 
the  food  taken  is  too  -little  for  any  very  marked  dilatation  to 
take  place  above  the  obstruction. 

The  form  of  carcinoma  usually  met  with  in  the  oesophagus 
is  the  ilat-  or  squamous-celled  epithelioma.  Ninety  per  cent. 
of  the  tumours  met  with  are,  according  to  Butlin,  of  this 
kind.  Both  forms  of  the  glandular-celled  carcinoma  have 
been  met  with  -  that  is,  the  scirrhous  and  medullary ;  an 
instance  also  of  the  colloid  form  has  been  recorded  by 
Bristowe.*  To  these  has  now  apparently  to  be  added  examples 
of  the  cylinder-celled  variety.  One  case  I  found  recorded  by 
Parmentier,^  who  presents  this  form  of  epithelioma  ('  cylindro- 
prismatique  ')  as  an  instance  of  extreme  rarity.  The  origin 
of  the  tumour  appears  to  have  been  in  the  oesophageal  glands. 
Another  case  is  mentioned  by  David  Newman.^ 

In  addition  to  the  diseased  centre  itself  in  the  oesophagus, 
extension  takes  place  into  the  neighbouring  and  distant 
organs  both  by  direct  continuity  and  by  means  of  the  lym- 
phatics. Thus  by  direct  extension  of  the  growth  the  lungs 
may  be  invaded,  or  the  heart ;  masses  of  tumour  may  exist 
in  the  tissue  surrounding  the  oesophagus,  either  in  the  thorax 
or  in  the  neck.  Secondary  nodules  may  be  found  in  the 
liver,  kidneys,  spleen,^  small  intestine,  mesenteric  glands, 
bones,  and  other  organs  and  tissues.  The  lymphatic  glands 
in  the  post-mediastinal  and  deep  cervical  regions  are  those 
most  frequently  involved.  Occasionally,  however,  more  dis- 
tant glands  are  attacked.  Thus  Parry  Price  -^  mentions  a  case 
where  the  glands  in  both  axillae,  and  both  posterior  triangles 
were  enlarged.  Various  inflammatory  lesions  from  perfora- 
tions are  sometimes  found.     These  may  take  the  form  of  an 

'    Trans.  Path.  Soc.  Lond.  1868,  vol.  xix.  p.  228. 

'^  Archives  Generales  de  Midecine,  1889,  vol.  1.  p.  470. 

3  Lancet,  1892,  vol.  i.  p.  9.  "  N.  Moore,  Lancet,  1883,  vol.  i.  ^.  13. 

^  Brit.  Med.  Journ,  1880,  vol.  i.  p.  08. 


(WIJCTNOMA  03 

ncntc  cellulitis  or  a  localised  abscess  when  the  perforation 
leads  into  cellular  tissue,  or  pericarditis  or  pleurisy  if  the 
pericardial  or  pleural  cavities  are  invaded.  When  the  bronchus 
or  lung  is  opened  into,  pneumonia  and  gangrene  are  the  usual 
sequels.  More  uncomroon  results  are  occasionally  met  with. 
Thus  in  a  case  recorded  by  Klein, ^  gangrene  of  the  left  auricle 
and  of  the  spleen  was  found  at  the  post  mortem ;  emboli 
existed  both  in  the  coronary  and  splenic  arteries.  Desmos  ^ 
draws  attention  to  three  cases  where  death  resulted  from 
pleuro-pneumonia,  and  in  none  of  these  was  there  perforation 
or  direct  extension  to  account  for  the  lung  lesion. 

Symptoms. — As  a  disease  of  itself,  carcinoma  occurring  in 
any  part  of  the  human  body  presents  one  common  and  usually 
constant  symptom,  that  of  progressive  emaciation  ;  but  the 
special  symptoms  which  become  peculiar  to  it  as  it  attacks 
various  parts  of  the  body  are  connected  largely  with  the 
functional  and  organic  disturbances  caused  by  its  develoj)ment 
in  that  particular  part.  So  here,  in  the  case  of  the  cesophagus, 
the  growth  of  the  tumour  within  the  canal  tends  to  obstruct 
its  calibre,  and  hence  from  that  obstruction  arises  some  of 
the  most  prominent  and  characteristic  features  of  the  disease. 

Although  not  the  usual  way  of  describing  the  symptoms 
of  the  disease,  and  taken  exception  to  by  some,  it  has  seemed 
to  me  likely  to  simplify  the  discussion  by  dividing  them  into 
local  and  general. 

Local  symptoms. — These  symptoms  are  connected  entirely 
with  the  tumour  within  the  canal,  and  are  among  the  earliest 
to  manifest  themselves.  Dysphagia  is  frequently  the  first 
symptom  which  indicates  the  onset  of  the  disease.  The 
patient's  attention  is  attracted  by  the  difficulty  in  swallowing 
certain  foods,  mostly  of  a  dry,  solid  consistency.  This  difficulty 
slowly  increases  until  it  is  found  that  unless  the  solid  food  is 
very  thoroughly  masticated  or  freely  moistened  with  fluids  it 
will  not  pass  into  the  stomach.  It  descends  a  certain  distance, 
remains  for  a  few  minutes,  and  is  then  gulped  np.  At  a  later 
stage  solids  under  any  form  will  not  pass,  and  the  patient 
finds  himself  forced  to  limit  his  nourishment  entirely  to  fluids. 
Still  later,  difficulty  is  experienced  in  swallowing  fluids,  and  in 

'  Archiv  fur  Path.  Anat.  1889,  Bd.  cxviii.  p.  G9. 
2  Eeviie  Mens,  de  Mid.  ct  de  Chir.  1879,  p.  19. 


64  THE   OESOPHAGUS 

the  latest  stage  little  or  nothing  can  be  got  to  pass  the 
obstruction-  It  not  unfrequently  happens  that  when  the 
obstruction  is  at  its  worst  a  sudden  and  marked  improvement 
takes  place.  This,  however,  is  only  temporary,  and  is  due  to 
the  accidental  removal  of  a  portion  of  the  growth,  v/hich 
renders  for  a  time  the  canal  more  permeable. 

A  sense  of  obstruction  is  often  experienced  by  the  patient. 
He  feels  the  place  at  which  the  food  lodges,  and  is  often  conscious 
— to  the  extent  sometimes  of  suffering  pain— of  its  slow  progress 
past  the  obstruction.  At  times  a  small  amount  of  bleeding 
may  take  place  from  the  ulcer,  and  the  patient  expectorates 
blood-tinged  mucus.  As  the  obstruction  increases  there  is 
an  inability  to  swallow  saliva,  and  hence  this  and  the  mucoid 
secretion  from  the  oesophageal  glands  cause  the  patient  to 
constantly  expectorate,  at  first  a  more  or  less  frothy  mucus, 
but  later  a  much  more  viscid  material. 

The  pain  experienced  is  variable  in  degree,  kind,  and  situa- 
tion ;  at  times  it  is  so  slight  that  but  little  more  than  a  feeling 
of  inconvenience  is  experienced ;  at  other  times  its  severity 
is  marked  by  sharp,  shooting,  or  burning  sensations  located 
behind  the  sternum,  in  the  epigastrium,  or  posteriorly  between 
the  shoulder  blades. 

General  symptoms. — Prominent  among  the  general  sym- 
ptoms is  the  progressive  and  rapid  emaciation.  Whatever  may 
be  the  amount  of  wasting  due  directly  to  the  growth  of  the 
tumour  itself,  it  is  largely  augmented  through  the  increasing 
diminution  of  nourishment  which  reaches  the  stomach.  This 
insufficiency  of  food  causes  at  the  earlier  stage  of  the  disease 
a  feeling  of  hunger,  but  this  soon  gives  place  to  sensations  of 
faintness.  The  stomach  also  suffers  from  the  want  of  its 
ordinary  stimulants,  and  fails  at  last  in  its  proper  digestive 
function,  so  that  not  infrequently  such  food  as  does  reach  it 
remains  for  some  time  in  an  undigested  condition.  Should 
vomiting  result  from  these  digestive  disorders,  much  pain  and 
inconvenience  are  experienced.  The  breath  frequently  becomes 
very  offensive,  due  in  some  cases  to  the  gastric  disturbances, 
and  in  others  to  ulceration  and  sloughing  at  the  seat  of  the 
disease.  Dryness  of  the  tongue  and  fauces,  with  troublesome 
thirst,  are  distressing  symptoms  towards  the  close.  The  bowels 
are  constipated. 


CARCINOMA  65 

Excluding  complications  wliicli  will  Lg  referred  to  later,  the 
above  local  and  general  symptoms  may  be  taken  as  examples 
of  those  most  commonly  met  with.  It  will  be  right,  however, 
to  allude  briefly  to  a  few  modifications  of  these  which  occasion- 
ally present  themselves. 

The  onset  of  the  disease  may  be  quite  sudden.  Several 
cases  have  now  been  recorded  where  the  patient  while  engaged 
in  eating  his  ordinary  meal  suddenly  encountered  difficulty  in 
swallowing  a  bolus  of  food.  In  Stanley  Boyd's  case '  the 
patient  from  that  moment  onwards  experienced  great  difficulty 
in  deglutition.  In  some  cases  published  by  W.  P.  Thornton  ^ 
and  by  Butlin,^  the  patients  had  enjoyed  perfect  health  up  to 
the  period  of  the  sudden  appearance  of  severe  obstruction. 

Again,  dysphagia  may  never  be  a  symptom  throughout  the 
disease  ;  thus  in  G.  E.  Paget's  case  ■*  pain  was  the  most  promi- 
nent symptom.  The  patient  never  complained  of  any  difficulty 
in  swallowing,  and  died  from  ulceration  extending  into  the 
aorta.  In  a  case  reported  by  Stockwell  •'"'  the  first  symptom 
of  dysphagia  was  concomitant  with  that  of  perforation  of  the 
bronchus.  In  the  case  of  Newman's*^  already  referred  to,  the 
earliest  symptoms  were  those  of  dyspepsia  and  regurgitation 
of  food.  Throughout,  this  patient  never  sufi'ered  from  pain. 
While  it  is  usual  for  food  to  be  almost  immediately  ejected 
after  being  swallowed,  it  is  sometimes  delayed  in  its  return ; 
thus  in  Eoosevelt's  case  already  quoted,  where  the  oesophagus 
was  enormously  dilated,  the  food  swallowed  did  not  return  often 
for  nearly  two  hours.  In  some  cases  so  little  like  the  ordinary 
symptoms  met  with  have  those  which  presented  themselves 
been,  that  a  mistaken  diagnosis  has  been  made.  In  a  case 
recorded  by  Smith  ^  the  earliest  symptoms  consisted  of  burning 
pain  in  the  stomach  of  considerable  severity,  heartburn,  water- 
brash,  and  pain  in  the  back  and  shoulders.  The  cause  was 
diagnosed  as  one  of  cancer  of  the  stomach,  but  was  subse- 
quently proved  to  be  disease  of  the  lower  third  of  the  oesophagus. 

'  Brit.  Med.  Journ.  1882,  vol.  i.  p.  538. 

2  Lancet,  1881,  vol.  i.  p.  617.  ^  Ibid.  p.  677. 

^  Brit.  Med.  Journ.  1882,  vol.  i.  p.  192.  »  Ibid.  vol.  ii.  p.  888. 

*  New  York  Med.  Journ.  1879,  vol.  xxx.  p.  158. 

'  Dublin  Journal  of  the  Medical  Sciences,  1880,  3icl  series,  vol.  Ixix.  p.  58. 

F 


66  THE   CESOPIIAGUS 

In  a  case  also,  reported  by  Finlayson,^  aphonia  was  such  a 
prominent  symptom  that  a  diagnosis  of  advanced  laryngeal 
phthisis  with  ulceration  was  iirst  formed.  The  case  subse- 
quently turned  out  to  be  one  of  cancer  of  the  oesophagus 
involving  the  left  recurrent  laryngeal  nerve.  In  Eoosevelt's 
case  the  diagnosis  was  chronic  gastritis.  In  Burnet's  case 
above  quoted  the  first  symptom  noted  was  a  sensation  of 
tickling  in  the  gullet.  It  was  not  until  six  months  later  that 
symptoms  of  dysphagia  showed  themselves. 

The  quantity  of  mucus  expectorated  varies  within  consider- 
able limits.  Sinclair  ^  reports  a  case  where  the  patient  brought 
up  every  day  a  quantity  of  glairy  mucus,  measuring  from  two 
to  fifteen  ounces,  in  much  the  same  way  as  he  rejected  food. 
This  glairy  substance  appears  to  have  been  saliva  that  collected 
in  the  cesophagus. 

Secondary  complications. — In  the  later  stages  of  the 
disease  symptoms  not  infrequently  arise  which  indicate  com- 
plications due  to  some  extension  of  the  disease  into  neigh- 
bouring organs  and  tissues.  Thus  dyspnoea  may  arise  from 
pressure  upon  or  invasion  of  the  trachea  ;  a  sudden  violent 
fit  of  coughing  arising  spontaneously  or  on  any  endeavour  to 
swallow  fluid  may  indicate  the  formation  of  a  communication 
between  the  oesophagus  and  the  main  air  passages.  A  sudden 
haBmorrhage  may  be  due  to  the  opening  of  a  blood  vessel ;  and 
here  it  may  be  remarked  that  any  vessel,  whether  vein  or  artery, 
lying  in  close  proximity  to  the  gullet  may  be  laid  open  by 
ulceration.  The  larger  the  vessel,  the  more  copious  and  serious 
will  naturally  be  the  haemorrhage.  Involvement  of  the  recurrent 
laryngeal  on  either  side,  although  the  left  is  more  frequently 
implicated,  may  cause  some  laryngeal  irritation  with  cough, 
or  complete  paralysis  of  one  vocal  cord  with  some  aphonia. 
A  rise  of  temperature,  with  other  concomitant  symptoms  of 
feverishness,  should  lead  to  suspicion  of  inflammation  arising 
somewhei'e.  This  may  be  of  the  nature  of  a  pleurisy,  a  peri- 
carditis, or  a  pneumonia,  in  which  case  the  symptoms  distinc- 
tive of  each  will  soon  serve  to  establish  the  diagnosis.  A  fulness 
or  hardness  in  the  neck,  with  increasing  redness  and  tenderness, 


'   Trans.  Path,  and  Clin.  Soc.  Glasgoiv,  1892,  vol.  iii.  p.  250. 
2  Brit.  Med.  Jvnrn.  1885,  vol.  i.  p.  594. 


CARCINOMA  et 

will  denote  cellulitis,  with  the  possible  formation  of  an  acute 
abscess.  When  considerable  pain  is  complained  of,  this  may 
be  due  to  secondary  deposits  in  the  bones.  In  the  case  recorded 
by  Finlayson  the  severe  abdominal  pain  from  which  the 
jtatient  suffered  turned  out  to  be  due  to  a  cancerous  tumour 
in  the  body  of  the  twelfth  dorsal  vertebra. 

Diagnosis. — It  is  not  a  matter  of  much  difficulty  to  diagnose 
a  case  of  carcinoma  of  the  oesophagus  when  the  patient  is  about 
the  age  at  which  the  disease  most  frequently  appears ;  when 
the  history  is  negative — that  is  to  say,  when  no  explanation 
is  forthcoming  to  account  for  the  onset ;  and  when  the  sym- 
ptoms both  local  and  general  are  in  every  way  characteristic 
of  the  complaint.  It  is  not,  however,  always  that  even  such 
evidence  is  deemed  sufficient,  and  something  further  is  done 
to  establish  the  diagnosis.  Although  the  advisability  of 
attempting  to  pass  a  bougie  has  often  been  disputed,  most 
surgeons,  I  venture  to  think,  nowadays  would  not  consider 
their  investigation  of  the  case  sufficient  without  resorting  to 
that  practice.  Its  advantages  are  threefold.  In  the  first  place 
it  serves  to  confirm  the  suspicion  of  some  obstruction ;  in  the 
second  it  locates  the  seat  of  the  disease ;  and  in  the  third 
it  may  indicate  to  some  degree  its  extent.  It  may  be  added 
further  that  inasmuch  as,  for  all  diagnostic  purposes,  the 
utmost  gentleness  is  exercised,  any  appearance  of  blood  after 
the  operation  would  strongly  suggest  ulceration ;  and  if  acci- 
dentally any  fragments  of  tissue  should  be  dislodged  and 
capable  of  being  submitted  to  the  microscopic,  the  diagnosis 
may  be  confirmed  beyond  all  doubt.  It  occasionally  happens 
that  the  evidence  of  an  obstruction  elicited  by  the  passage  of 
a  bougie  proves  to  be  misleading.  Thus  it  is  by  no  means 
common  to  find  a  certain  amount  of  spasm  associated  with 
malignant  disease,  and  when  this  affects  a  part  of  the  canal 
not  at  the  seat  of  the  disease,  nor  in  its  immediate  proximity, 
a  false  conclusion  of  the  true  seat  of  the  obstruction  may  be 
easily  arrived  at.  Such  an  error  in  diagnosis  occurred  in  two 
cases  recorded  by  Lacombe.'  In  one  the  seat  of  obstruction 
was  diagnosed  as  complete  at  a  point  near  the  cardiac  orifice. 
At    the   post   mortem,    carcinoma   was    found    affecting   the 

'   Gazette  Hebdom.  de  Mi'd.  ct  de  Chir.  2®  strie,  tome  xxii.  p.  189. 

F  2 


68  THE    CESOPHAGUS 

oesophagus  opposite  the  bifurcation  of  the  trachea,  while  the 
remainder  of  the  canal  was  perfectly  healthy.  In  the  second 
case  the  post  mortem  revealed  extensive  carcinoma  of  the 
stomach,  with  a  perfectly  healthy  oesophagus.  During  life  an 
obstruction  was  encountered  a  little  below  the  pharynx. 

The  seat  of  the  disease  is  often  accurately  localised  by 
the  patient  himself.^  He  is  conscious  of  a  certain  spot  where 
the  food  seems  to  lodge,  and  he  is  also  conscious  of  certain 
sensations  while  the  bolus  passes  the  obstruction.  Inde- 
pendently, however,  of  the  passage  of  food,  pain  itself  is 
sometimes  felt,  and  correctly  localises  the  focus  of  disease. 
On  the  other  hand  the  patient's  feelings  must  not  always  be 
accepted  as  accurately  settling  this  point,  for  sometimes  the 
pain  is  felt  at  a  considerable  distance  from  the  affected  area : 
thus  it  may  be  felt  at  the  top  of  the  sternum  when  disease  is  much 
lower.  A  surer  means  of  focalising  the  locality  of  the  mischief 
is  by  auscultation  and  by  using  the  oesophagoscope.  The  latter 
is  of  most  service  when  the  disease  is  situated  in  the  upper 
part  of  tbe  canal,  and  the  former  for  obstruction  anywhere  in 
the  thoracic  portion.  In  auscultation,  the  patient  is  made  to 
swallow  some  fluid,  and  the  ear  is  applied  either  directly  or  by 
means  of  the  stethoscope  to  the  spine.  In  this  way  various 
sounds  may  be  heard  indicative  of  the  fluid  passing  through  a 
constricted  canal.  Further,  if  we  remember  the  fact  pointed 
out  by  Ogston,'  that  the  time  of  passages  of  fluids  into  the 
stomach  is  in  the  normal  condition  about  four  seconds,  any 
increase  of  this  period  will  suggest  obstruction.  In  a  case 
recorded  l>y  Hunter  Mackenzie  ^  the  time  taken  was  from  ten 
to  twelve  seconds.  This  method  of  examination,  however,  is 
not  so  easy  as  it  might  at  first  sight  appear,  and  requires  more 
experience  than  most  practitioners  usually  have,  to  enable  a 
correct  diagnosis  to  be  made,  except  in  the  most  striking  cases. 
The  oesophagoscope  may  prove  of  more  service  than  for  the 
mere  detection  of  a  tumour.  Thus  Morell  Mackenzie  ^  was 
enabled  not  only  to  see  a  growth  about  three  inches  below  tbe 
cricoid  cartilage,  but  to  remove  a  fragment  for  microscopic 
examination.     The  possibility  of  determining  with  any  degree 

'  See  page  4. 

-  Jcmrnal  of  Laryngology  and  Ehinology,  1891,  vol.  v.  p.  51. 

■'  Medical  Times  and  Gazette,  1881,  vol.  ii.  p.  GO. 


PLATE    IV. 


Fig.  8 —Carcinoma  of  CEsophagus  — The  gullet  is  involved  for  about  i^  inch. 
The  lower  limit  is  one  inch  from  the  cardiac  orifice.  The  aorta  is  seen  laid 
open  on  the  right.     ( W.I.OVI.,  Glas.) 


CARCINOMA  69 

of  certainty  the  particular  kind  of  tumour  present  is  doubtful, 
but  a  tolerably  correct  guess  can  often  be  made.  Thus  the 
course  run  by  a  scirrhous  carcinoma  is  usually  much  longer 
than  that  in  the  more  frequently  met  with  epithelioma.  On 
the  other  hand,  the  rarer  form  of  medullary  cancer  runs  a 
rapid  course.  Again,  any  foetor  in  the  breath,  or  in  the  matter 
removed  either  naturally  in  vomiting  or  artificially  by  the 
bougie,  will  indicate  sloughing  of  parts. 

Differential  diagnosis. — The  distinction  between  carcinoma 
of  the  oesophagus  and  other  diseases  simulating  it  may  be 
considered  under  two  heads.  First  where  the  disease,  what- 
ever it  may  be,  unmistakably  involves  the  oesophagus  ;  and 
second,  where  it  is  located  elsewhere.  In  the  former  instance 
it  is  usually  the  condition  of  obstruction  with  its  pathogno- 
monic symptom,  dysphagia,  that  most  prominently  calls  for 
consideration  and  diagnosis.  The  various  conditions  which 
may  give  rise  to  symptoms  of  obstruction  may  exist  either 
within  or  without  the  canal.  In  the  latter  case  the  tube  is 
pressed  upon  by  some  tumour  or  swelling,  such  as  aneurysm 
of  the  arch  of  the  aorta,  spinal  abscess,  malignant  disease  of 
neighbouring  parts,  &c.  In  all  these  cases  there  is  usually 
but  little  difficulty  in  passing  a  bougie,  and  the  symptoms 
peculiar  to  each  affection  are  sufficient  of  themselves  to  indi- 
cate the  real  cause  of  the  obstruction.  Among  the  intrinsic 
affections  of  the  canal  may  be  mentioned  stricture  arising 
either  from  traumatism,  syphilis,  chronic  ulcer,  or  some 
spasmodic  nerve  affection,  chronic  oesophagitis,  paralysis, 
simple  dilatation. 

In  the  case  of  obstruction  due  either  to  a  traumatic  or  a 
syphilitic  stricture,  the  previous  history  of  the  case  in 
each  instance  will  largely  assist  in  determining  the  nature 
of  the  obstruction.  In  the  case  of  stricture  following  a 
simple  ulcer  of  the  oesophagus,  there  will  usually  be  some 
history  of  previous  haemorrhages,  taking  place  at  intervals 
of  time  too  distant  from  the  actual  onset  of  dysphagia 
to  admit  of  a  diagnosis  of  carcinoma  being  entertained  (see 
Debove's  case  above,  p.  48).  In  strictures  of  a  spasmodic 
character,  there  will  usually  be  some  nerve  element  in  the  case 
to  excite  a  suspicion  as  to  its  nature,  and  in  addition  the 
passage  of  a  bougie  while  the  patient  is  under  an  anaesthetic 


70  THE   (ESOrilAGUS 

will  prove  the  absence  of  any  organic  obstruction.  Hot  water 
swallowed  in  the  case  of  simple  spasm  is  generally  at  once 
ejected,  while  in  cancer  it  is  more  likely  to  be  retained  (Gant). 
A  paralytic  condition  of  the  oesophagus  giving  rise  to  dys- 
phagia is  uncommon,  and  usually  found  in  those  whose  strength 
is  greatly  reduced  either  from  old  age  or  some  prolonged 
exhausting  disease.  The  bougie  passes  easily,  and  so  excludes 
the  existence  of  any  mechanical  obstruction.  Dysphagia 
from  chronic  oesophagitis  is  distinguished  with  difficulty 
from  that  produced  by  carcinoma.  Occurring  about  the 
same  time  of  life  and  in  those  who  are  in  robust  health,  the 
diagnosis  has  to  rest  mostly  in  the  progress  of  the  case. 
Some  assistance,  however,  may  be  lent  towards  making  a 
diagnosis  by  the  fact  that  in  the  inflammatory  condition 
considerable  pain  is  experienced  in  attempting  to  swallow  hot 
or  irritating  substances  ;  and  that  in  the  passage  of  a  bougie 
great  discomfort,  if  not  pain,  is  complained  of.  Under  careful 
treatment — by  excluding  all  causes  of  irritation — rapid  im- 
provement ensues,  and  any  further  difficulty  in  coming  to  a 
diagnosis  is  removed.  Simple  dilatation  of  the  oesophagus  is  a 
condition  which  usually  arises  early  in  life.  Although  accom- 
panied with  vomiting  after  food,  the  ejection  does  not  usually 
take  place  for  an  hour  or  two.  The  comparatively  easy  passage 
of  a  full-sized  bougie  will  serve  to  prove  that  the  symptoms 
are  not  due  to  real  obstruction. 

Eeher,'  in  an  interesting  paper,  describes  how  in  various 
ways  obstruction  in  the  oesophagus  may  be  produced  through 
disease  of  the  stomach.  Carcinoma  affecting  the  cardiac  end 
of  that  organ  may  narrow  the  orifice  of  the  oesophagus,  through 
the  growth  of  tumour  around  it ;  or  it  may  so  deflect  the 
normal  perpendicular  axis  of  the  gullet  as  to  cause  it  to  form 
an  acute  angle  with  the  stomach. 

Carcinoma  of  the  liver  produces  in  some  cases  symptoms 
suggestive  of  obstruction  in  the  oesophagus,  and  has  been  the 
cause  of  a  mistaken  diagnosis.     ( See  Spasm  of  CEsophagus.) 

Disease  of  the  oesophagus  is  liable  to  be  masked,  by  the 
reference  of  the  symptoms  to  adjoining  organs.  The  cases 
where  these  difficulties  are  liable  to  arise  are  those  in  which 

'  Dcutsches  Archiv  filr  Klin.  Med.  1885,  Bd.  xxxvi.  p.  460. 


CARCINOMA  71 

the  symptoms  point  to  disease  either  of  the  stomach  or  of 
the  air  passages.  In  one  case  (Smith's)  ah-eady  referred  to 
(p.  G5),  the  symptoms  of  the  oesophageal  disease  were  so  like 
those  arising  from  disease  of  the  stomach,  that  the  diagnosis 
made  was  carcinoma  of  that  organ.  In  Eoosevelt's  case 
(j).  61)  also,  the  symptoms  were  so  strongly  referable  to  the 
stomach  that  a  diagnosis  of  chronic  gastritis  was  mad  . 
Page  ^  reports  the  case  of  a  man  aged  65  years  who  pre- 
sented the  symptoms  of  tuberculous  disease  of  the  cervical 
vertebrse.  The  head  was  bent  forward,  and  the  neck  pre- 
sented a  projection  behind.  There  was  loss  of  power  in  the 
extremities,  and  retention  of  urine.  No  evidence  of  obstruc- 
tion of  the  oesophagus.  At  the  post-mortem  examination 
carcinoma  of  the  gullet  was  found  encircling  its  whole  circum- 
ference, but  not  narrowing  the  lumen.  A  mass  of  growth  had 
made  its  way  through  the  intervertebral  foramina  on  the 
right  side  into  the  spinal  canal,  and  caused  softening  of  the 
cord. 

In  the  case  of  symptoms  suggesting  disease  of  the  air 
passages  it  not  infrequently  happens  that  cough  is  the  mis- 
leading symptom,  or  aphonia,  as  in  Finlayson's  case  (p.  66), 
where  the  diagnosis  made  was  *  advanced  laryngeal  phthisis 
with  ulceration.'  Gaucher  ^  records  a  case  where  the  early 
symptoms  were  of  such  a  pronounced  laryngeal  character,  that 
tracheotomy  had  to  be  performed.  Subsequently  dysphagia 
and  other  symptoms  of  oesophageal  stricture  manifested  them- 
selves, and  it  was  discovered  that  the  initial  symptoms  were 
due  to  an  early  involvement  of  both  recurrent  laryngeal  nerves. 
In  cases  of  supposed  laryngeal  trouble  the  laryngoscope  will 
often  assist  in  eliminating  affection  of  that  region.  It  may  be 
mentioned  lastly  that  the  seat  of  pain  may  sometimes  prove 
misleading.  In  Finlayson's  case  abdominal  pain  was  a  most 
prominent  and  puzzling  symptom  ;  and  was  due,  as  shown  at 
the  post  mortem,  to  a  secondary  nodule  in  the  body  of  the 
twelfth  dorsal  vertebra. 

These  varied  and  exceptional  conditions  are  only  mentioned 
in  order  to  render  the  surgeon  alive  to  the  fact  of  their  exist- ' 
ence,  so  that  when  obscure  and  unaccountable  symptoms  do 

'  Medical  Press  aiid  Circular,  1892,  vol.  i.  p.  413. 

^  Journal  of  Laryngology  and  Rhinology,  1890,  vol.  iv.  p.  512. 


72  THE   (ESOPHAGUS 

arise  he  may  not  be  misled  into  attributing  them  to  causes 
which,  on  the  surface,  they  seem  to  suggest. 


CHAPTEK  VIII 
CARCINOMA  (continued),     prognosis  and  treatment 

Prognosis. — In  the  majority  of  instances  death  takes  place 
from  exhaustion  within  a  year  from  the  onset  of  the  first 
symptoms.  Often  the  period  is  much  less.  In  Mackenzie's 
hundred  cases  the  average  length  of  life,  after  the  first 
symptoms  were  unmistakably  manifested,  was  eight  months 
— the  maximum  being  sixteen  months  and  the  minimum  five 
weeks.  In  a  case  reported  by  Owles,^  the  patient  lived  for 
three  years  after  the  first  appearance  of  symptoms.  The  many 
accidents  which  may  happen  in  the  progress  of  the  disease 
render  it  impossible  to  venture  upon  anything  but  the  merest 
speculation  as  to  the  length  of  life.  Haemorrhage,  if  not  at 
once  fatal,  must  be  considered  as  a  grave  forerunner  of  not 
very  distant  dissolution.  Perforation  into  the  air  passage  will 
cause  death  within  a  week  or  two.  Barring  such  accidents, 
life  may  be  measured  by  the  general  physical  conditions  of 
the  patient.  Towards  the  latest  stage  of  the  disease  consider- 
able improvement  sometimes  takes  place  in  the  patient's  ability 
to  swallow.  This  is  due  to  some  dislodgment  of  the  growth, 
and  is  of  course  only  temporary  improvement.  To  what 
extent,  however,  such  improvement  may  take  place  is  illus- 
trated in  a  case  recorded  by  Henschell.^  Two  days  after  the 
passage  of  a  bougie  the  patient  spat  up  two  large  quantities 
of  blood.  Soon  after  that  his  condition  began  to  improve,  and 
he  took  milk  freely.  He  gained  twenty-five  pounds  in  weight, 
and  remained  comfortable  till  three  days  before  death,  when 
he  developed  lung  symptoms  from  perforation.  In  somewhat 
strikmg  contrast  to  the  result  of  passing  a  bougie  in  this  case, 
I  may  allude  to  a  rather  unusual  sequel  recorded  by  Fort."* 
The  patient  had  been  accustomed  to  pass  the  bougie  himself, 

'  Medical  Press  and  Circular,  1886,  N.S.  vol.  xlii.  p.  427. 
*  New  York  Medical  Record,  1883,  vol.  xxiv.  p.  635 
^  Gazette  des  Hopitaux,  1883,  vol.  Ivi.  p.  1010. 


CARCINOMA  73 

and  on  this  occasion  when  attempting  to  do  so,  suddenly 
expired.  As  no  important  structure  had  been  perforated,  Fort's 
explanation  was  that  either  the  vagus  or  the  oesophageal 
plexus  had  been  irritated,  and  so  reflexly  stopped  the  heart, 
the  patient  dying  from  sj'^ncope. 

Where  it  is  possible  to  adopt  some  conservative  measures 
in  the  way  of  treatment,  hfe  may  be  considerably  prolonged. 
The  question  of  the  total  extirpation  of  the  disease  is  not  one 
which  at  present  it  is  possible  to  take  into  consideration  in 
giving  a  prognosis.  While  operations  have  been  suggested 
and  endeavours  made  for  the  excision  of  the  tumour,  whether 
located  in  the  cervical  or  the  thoracic  portion  of  the  oesophagus, 
nothing  is  yet  sufficiently  settled  to  enable  any  opinion  to  be 
expressed  either  for  or  against  the  prolongation  of  life  after 
any  such  attempt. 

Treatment. — In  a  disease  which  is  practically  incurable  the 
treatment  consists  in  such  measures  as  will  most  conduce  to 
the  prolongation  of  life  and  the  relief  of  suffering.  It  will 
simplify  the  discussion  of  the  subject  to  consider  the  treat- 
ment of  oesophageal  carcinoma  under  the  four  stages  into 
which  the  progress  of  the  disease  may  be  divided.  These 
are, 

(1)  Early  symptoms  of  dysphagia,  but  with  ability  to 
swallow  solid  food.  (2)  Inability  to  swallow  solids,  but  ability 
to  take  fluids.  (3)  Aphagia,  or  total  inability  to  take  fluids. 
(4)  Complications  such  as  arise  from  fistulous  communications 
with  air  passages  &c. 

(1)  With  comparatively  few  exceptions — such  as  those 
already  alluded  to,  where  the  onset  of  the  dysphagia  is  sudden 
and  severe — the  condition  most  frequently  met  with  is  that  of 
some  slowly  increasing  difficulty  in  deglutition.  The  patient 
has,  as  a  rule,  already  learnt  the  secret  of  how  best  to  get 
solids  most  easily  into  the  stomach.  If  not  previously  mixing 
well  the  solid  with  some  fluid,  he  immediately  swallows  a 
mouthful  of  fluid  after  taking  the  solid  '  to  make  it  go.'  The 
treatment  therefore  at  this  comparatively  early  stage  of  the 
disease  consists  almost  solely  in  a  careful  selection  of  suitable 
foods.  The  foods  must  be  of  the  most  nutritious  kind,  free 
from  irritating  properties,  and  without  such  condiments 
as  pepper  and  mustard.      They   should  also   be  of  such    a 


74  THE   (ESOPHAGUS 

character  and  consistency  that  they  can  easily  mould  them- 
selves to  the  narrowed  and  distorted  passage  through  which 
they  have  to  pass.  Taken  in  small  mouthfuls,  and  either 
well  masticated  or  previously  mechanically  broken  up,  a 
patient  will  frequently  be  able  to  make  a  good  meal,  when 
without  such  simple  precautions  but  little  solid  food  might  be 
swallowed.  The  foods  which  will  be  found  to  best  subserve 
these  requirements  will  be — among  those  of  a  nitrogenous 
kind — oysters,  boiled  or  stewed  tripe,  boiled  calf's  or  sheep's 
head,  stewed  pig's  and  calf's  feet,  eggs,  &c. ;  and — among 
those  of  a  farinaceous  kind — porridge,  arrowroot,  boiled  sago, 
ground  rice,  &c.  Occasionally,  as  pointed  out  by  B.  W.  Eichard- 
son,^  it  will  be  found  that  cold  materials  are  taken  better 
than  warm  or  hot.  As  the  time  approaches  when  even  these 
bland  foods  are  beginning  to  pass  with  difficulty,  the  question 
of  instrumentation  arises.  Now  will  be  the  time  for  the 
systematic  passage  of  bougies.  Twice  a  week,  or  oftener,  a 
bougie  should  be  passed.  Such  a  practice  will  serve  to  extend 
the  time  during  which  a  patient  will  be  enabled  to  continue 
taking  solid  foods.  When,  however,  this  means  fails,  we  have 
to  face  the  second  stage,  that  of  total  inability  to  swallow 
solids. 

(2)  Patients  who  are  reduced  to  depend  solely  upon  fluids 
for  nutrition  rapidly  emaciate,  and  the  question  of  treatment 
no  longer  turns  upon  the  kind  of  nourishment  to  be  adminis- 
tered, but  upon  certain  considerations  connected  with  the 
question  of  operative  interference. 

So  much  success  has  attended  in  recent  years  the  use  of 
tubes  retained  for  lengthened  periods,  that  few  surgeons,  at 
this  Rtage  of  the  disease,  would  venture  upon  more  serious 
operative  measures.  Those  who  have  tried  this  method  are 
loud  in  its  praise  when  compared  with  the  alternative  of 
gastrostomy;  and  those  who  advocate  the  latter  method,  it 
must  be  confessed,  frequently  do  not  appear  to  have  tried  the 
former. 

While  the  use  of  tubes  for  purely  feeding  purposes  has 
long  been  in  vogue,  it  is  only  in  comparatively  recent  years 
that  the  idea  of  inserting  a  tube  and  allowing  it  to  remain 
permanently  in  situ  has  come  into  practice.     Prior  to  1881 

'  Asclepiad,  1886,  vol.  iii.  p.  05. 


PLATE    V. 


Fijf.  ci. — Carcinoma  of  the  Lower  End  of  the  CEsophagls. — The  canal,  to  the 
extent  of  i'/^  inch,  is  converted  into  a  thick-walled  cylinder  with  a  narrow 
calibre.  There  is  dilatation  of  the  gullet  above,  which  measured  in  cir- 
cumference about  3J4  inches.     (W  I.M.,  Glas.) 


CAUCINOMA  75 

Morell  Mackenzie  '  speaks  of  having  for  years  used  a  Bhort 
tube,  allowing  it  to  remain  in  position  for  five  or  six  days  and 
then  removing  it.  But  it  was  in  this  year  that  Krishaher,  at 
the  International  Medical  Congress,  gave  a  renewed  impetus 
to  this  method  of  treatment  by  introducing  cases  where  the 
tubes  had  been  worn  for  prolonged  periods.  Since  this  numer- 
ous surgeons,  among  them  Durham,  Croft,  Symonds,  Berry, 
Pienvers,  Gersmiy,  and  others,  have  recorded  cases,  and 
improved  in  certain  details  the  method  of  treatment  by 
permanent  tubage. 

To  Symonds  ^  in  this  country  must  be  attributed  the  most 
active  advance,  both  as  regards  the  number  of  patients  he  has 
successfully  treated  and  the  manner  of  procedure.  His 
exhaustive  and  interesting  papers  should  be  consulted  for  a 
fuller  discussion  of  the  subject  than  can  be  entered  upon  here. 
I  shall,  however,  quote  his  directions  for  the  use  of  the  per- 
manent short  tube. 

'  First  ascertain  by  a  large  bougie  the  exact  position  of  the 
stricture — i.e.  the  number  of  inches  from  the  teeth  ;  then  pass 
the  largest  conical  bougie  possible,  and  judge  by  this  the  size 
of  the  tube  to  be  used.  Fitting  now  the  introducer  '  (made  of 
whalebone  and  enclosed  by  a  gum  elastic  sheath),  '  mark  on 
it  the  distance  to  the  stricture,  or  make  a  knot  in  the  silk  ' 
(the  cords  which  are  attached  to  the  upper  dilated  part  of  the 
tube),  *  and  insert  with  the  head  thrown  back.  When  it  has 
entered  the  stricture  send  the  tube  down  slowly,  till  arrested 
by  the  funnel,  and  withdraw  the  introducer.  The  silk  being 
kept  taught,  the  tube  is  kept  in  contact  with  the  introducer. 
...  It  is  essential  to  avoid  hurry  and  force,  to  withdraw  at 
once  if  there  be  a  spasm,  and  to  keep  in  the  median  line. 
The  silk  is  now  tied  round  the  ear,  and  fixed  behind  by  a 
piece  of  strapping.' 

The  time  during  which  a  tube  should  be  retained  will 
depend  upon  various  circumstances.  After  a  week  or  ten 
days  it  will  sometimes  be  found  that  the  first  tube  can  be 
removed  and  replaced  by  another  of  larger  calibre,  and  this 
process  may  be  continued  at  similar  intervals  until  the  largest 
size  is  reached.     When  a  tube  of  this  size  has  been  kept  in  place 

'  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  22. 
^  Lancet,  1889,  vol.  i.  p.  622. 


76 


THE   (ESOPHAGUS 


for  a  week  or  two,  it  may  be  removed,  and  the  patient  allowed 
to  swfJlow  some  solid  food,  which  otherwise  he  is  unable  to 


Fig.  10. — Symonds's 
Short  Tube  fob 
Cancee  of  the 
(Esophagus 


Fig.  12. — Svmonds's  ShoriTube 
in  situ 

A,  Upper  aperture  of  larynx  ;  b,  ceso" 
phagus  laid  open  from  behind  ;  c,  silk 
threiid  by  which  the  tube  is  retained 
in  position  and  withdrawn  ;  D  wide 
upper  end  of  the  tube  above  the  stric- 
ture ;  B,  narrower  lower  part  of  tube 
below  the  •  stricture  ;  F,  cardiac  end 
of  stomach. 


Fig.    11. — Symonds's  Short  Tube 

WITH  InTKODUCEH  HEADY  FOK  USE 


CARCTXOMA  77 

do.  In  tlie  use  of  these  short  tubes  there  is  the  possil)le 
danger  of  the  tube  becommg  disconnected  from  its  cords,  eitlicr 
from  the  latter  being  severed  by  the  friction  of  the  teeth,  or 
breaking  in  any  forcible  endeavour  at  extraction.  An  in- 
stance of  the  former  accident  is  recorded  by  G.  H.  Eodman.' 
The  tube  remained  in  for  twenty-four  weeks,  when  the  patient 
accidentally  coughed  it  wp.  Symonds  instances  one  of  his  own 
cases,  where  he  was  obliged  to  force  the  tube  into  the  stomach, 
the  cord  having  been  broken  in  an  endeavour  to  withdraw  a 
plugged  tube.  After  the  death  of  the  patient  from  the  disease, 
the  tube  was  found  in  an  undigested  condition  in  the  duo- 
denum. He  also  refers  to  another  case,  where  sixteen  days 
after  the  tube  had  passed  from  its  position  it  appeared  in  the 
faeces.  In  both  Eodman's  and  Symonds's  cases  the  accident 
was  apparently  preventable.  Eodman  in  a  second  case  used 
'  gimp  '  instead  of  silk,  and  when  it  passed  between  the  teeth, 
ran  the  gimp  through  a  piece  of  rubber  drainage  tube.  In 
Symonds's  case  the  accident  was  owing  to  the  tube  becoming 
blocked  ;  and  by  the  patient's  efforts,  carried  so  far  down,  that 
the  cords  were  put  unduly  on  the  stretch,  and  would  not  bear 
the  additional  strain  exercised  in  trying  to  withdraw  the  tube. 
The  narrower  the  tube  used,  the  greater  needs  to  be  the  care 
taken  with  the  food  swallowed.  In  all  cases  it  must  be  of  a 
perfectly  fluid  character. 

Gersuny's  ^  method  of  permanent  tuhage. — In  this  method 
of  treatment  the  tubes  can  neither  be  termed  examples  of  the 
'  short '  kind  nor  of  the  '  long.'  They  pass  from  the  stomach 
to  the  upper  orifice  of  the  oesophagus.  Two  ordinary  rubber 
drainage  tubes  are  taken  and  stitched  together,  the  sizes 
selected  being  suitable  for  the  case  in  hand.  The  upper  ends 
are  cut  in  such  a  way  as  to  leave  a  kind  of  ribbon-shaped 
strip  extending  from  the  upper  part  of  the  oesophagus  to  the 
posterior  nares.  To  each  end  is  fixed  a  thread  which  passes 
through  the  corresponding  nasal  cavity,  and  the  two  are  tied 
together  in  front  of  the  septum.  The  tubes  exiend  the  whole 
length  of  the  oesophagus,  and  the  two  ends  in  the  stomach  are 
so  cut  as  to  have  the  appearance  of  a  swallow's  tail.  This 
particular  shape  effects  a  sort   of  valvelike   action  whereby 

'   Brit.  Med.  Journ.  1880,  vol.  i.  p.  11G9. 

-  Wiener  Med.  Wochciiscliriff,  1887,  No.  48,  p.  13<).3. 


78  THE   ffiSOPITAGUS 

food  is  prevented  from  regurgitating.  Gersuny  adopted  the 
method  in  two  cases.  One  was  a  case  of  carcinoma,  and  the 
tube  was  retained  for  five  weeks. 

It  may  be  added  here  that  some  amount  of  success  has 
been  attained  in  the  dilatation  of  mahgnant  stricture  by  the 
use  of  laminaria.  Senator/  of  Berhn,  has  used  this  form  of 
tent.  It  is  fixed  on  to  the  end  of  a  bougie  and  passed  into 
the  stricture,  where  it'is  left  for  half  an  hour  or  longer.  Being 
secured  by  a  piece  of  silk,  it  is  easily  withdrawn.  The 
method  of  treatment  is,  however,  more  suitable  for  non- 
malignant  cases,  where  it  will  be  more  fully  referred  to. 

(3)  In  hospital  practice  it  frequently  happens  that  not  a 
few  of  the  patients  who  present  themselves  for  admission 
are  cases  of  aphagia  or  complete  inability  to  swallow  fluids. 
In  these  instances  the  patients  are  much  emaciated;  greatly 
reduced  in  strength,  and  show  signs  of  sinking  from  star- 
vation. When  thus  first  seen  it  will  often  be  found  impossible 
to  pass  the  smallest  bougie,  and  no  repeated  attempts  should 
be  made  for  a  day  or  two.  The  patient  should  be  confined  to 
bed,  kept  warm,  and  fed  by  nutrient  enemata  containing 
opium.  To  quench  thirst  a  little  ice  should  be  sucked,  but 
warm  water  may  be  given  by  rectal  injection.  On  the  second 
or  third  day  a  renewed  endeavour  should  be  made  to  pass  a 
bougie  ;  but  x>rior  to  the  attempt  subcutaneous  injections  of 
morphia  should  be  given  and  the  patient  placed  undei-  the 
influence  of  an  ansesthttic.  If  a  bougie  can  be  passed,  then 
further  dilatation  may  be  effected,  until  a  tube  can  be  intro- 
duced, and  the  treatment  by  that  method  continued.  Failing, 
however,  to  obtain  any  passage  past  the  obstruction,  the  only 
alternative  is  gastrostomy  if  the  disease  is  situated  in  the 
thoracic  portion  of  the  canal,  or  cesophagostomy  if  the 
disease  is  sufficiently  high  up  to  admit  of  the  opening  being 
made  below  it. 

(4)  While  I  have  placed  as  a  fourth  stage  of  the  disease 
the  existence  of  complications  through  the  extension  of  the 
growth  to  neighbouring  parts,  it  must  be  remembered  that 
these  may  arise  at  any  period  in  its  progress,  although  more 
frequently  appearing  after  the  disease  has  lasted  for  some  time. 
Whether ,  however ,  arising  early  or  late,  the  treatment  will  consist 

'  Brit.  Med.  Joiirn.  1889,  vol.  i.  p.  1417. 


CARCINOMA  79 

either  in  the  use  of  the  long  tube  permanentlj^  retained  or  in  the 
performance  of  gastrostomy.  When  a  choice  exists,  those 
surgeons  who  have  had  experience  of  the  former  measure  will 
select  it  in  preference  to  the  latter,  and  gastrostomy  will  only 
be  adopted  as  a  dernier  ressort.  The  '  long  '  tube  is  of  most 
service  in  cases  where  ulceration  has  taken  place  into  the 
pleural  cavity,  lungs,  bronchi,  or  trachea,  and  in  some  cases 
where  the  disease  is  situated  so  high  up  that  a  '  short '  tube 
cannot  be  worn.  Again,  where  there  is  reason  to  believe,  from 
the  offensiveness  of  the  breath  and  other  symptoms,  that  the 
disease  is  extensive  and  that  the  wall  of  the  oesophagus  is  both 
sloughing  and  thin,  the  '  long '  tube  will  prove  of  value. 

The  '  long '  tube  passes  from  the  stomach  out  through  the 
mouth  or  the  nostril.  If  no  inconvenience  is  associated  with 
its  retention,  it  may  be  kept  in  for  lengthened  periods.  Thus 
in  four  of  Krishaber's  ^  cases  the  respective  periods  of  retention 
were  305  days,  46  days,  167  days,  and  126  days.  In  one  of 
Symonds's  cases  it  was  worn  for  four  and  a  half  months.  As 
all  food  is  injected  into  the  stomach  through  the  tube,  there 
is  an  absence  of  those  troublesom.e  symptoms  which  would 
arise  from  the  escape  of  material  through  any  fistulous  open- 
ings into  the  air  passage  and  elsewhere.  If  for  any  reason, 
such  for  example  as  undue  irritation,  it  be  found  impos- 
sible to  retain  the  tube  permanently,  it  must  then  be  used 
simply  as  a  feeding  tube,  to  be  removed  and  introduced  as 
required. 

"While  special  '  long '  tubes  can  be  obtained,  it  is  of  service 
to  the  surgeon  to  know  that  for  all  practical  purposes  and  in 
cases  of  urgency  a  ver}'  simple  device  will  suffice.  These  are 
Symonds's  ^  directions  for  the  construction  of  a  '  long '  tube  '  in 
a  few  minutes  '  :  '  Take  a  piece  of  red  rubber  drainage  tube 
with  a  thin  wall  and  a  wide  bore,  and  about  eighteen  inches  long. 
Cut  one  end  obliquely  and  sew  it  up,  thus  obtaining  a  conical 
end ;  next  cut  a  large  eye  in  the  tube  about  an  inch  from  the 
extremity ;  or  two  openings  may  be  made.  To  prevent  the 
introducer  catching  in  the  point,  fill  up  the  interior  where 
stitched  with  a  plug  of  cotton  wool.  Oil  the  interior  of  the 
tube  and  introducer  thoroughly.     Insert  this  with  the  whale- 

'   Transactions  of  the  International  Medical  Congress,  1881,  vol.  ii.  ]}.  393. 
=  Lancet,  1889,  vol.  i.  p.  ()22. 


80  THE   (ESOPHAGUS 

bone  introducer  ;  .  .  .  the  outside  diameter  of  the  tube  need 
not  be  more  than  a  No.  12  catheter.' 

One  of  the  most  troublesome  objections  to  the  use  of  a 
permanent  long  tube  is  the  irritation,  resulting  sometimes  ia 
ulceration,  which  takes  place  on  the  posterior  surface  of  the 
cricoid,  due  to  the  constant  pressure  of  the  tube  on  that  part. 
This  is,  however,  reduced  to  a  minimum  by  using  as  soft  and 
flexible  tubes  as  possible. 

I  have  left  for  separate  and  fuller  consideration  the 
question  of  operation.  The  cesophagus,  like  almost  every  other 
region  of  the  body,  has  not  escaped  the  surgeon's  endeavour 
to  totally  extirpate  the  disease.  Hence  scattered  cases  are 
found  where  the  operation  of  removing  portions  of  the 
oesophagus  has  been  performed.  Originally  suggested  by 
Billroth  '  in  1872,  and  successfully  performed  by  him  on  dogs, 
it  was  first  apparently  executed  on  man  by  Kappe^er  ;  but 
not  till  1878  was  the  operation  successfully  carried  out  by 
Czerny,  who  in  a  private  letter  to  Morell  Mackenzie^  stated 
that  the  patient  lived  for  a  year  after  the  operation.  Wilms, ^ 
of  Boon,  reports  the  case  of  a  man  aged  46.  He  died  of 
haemorrhage  thirteen  days  after  the  operation.  In  these  in- 
stances the  disease  was  located  in  the  cervical  portion  of  the 
canal,  but  a  bolder  procedure  has  recently  been  suggested 
by  Nassiloff ''  of  excising  the  part  when  situated  within  the 
thoracic  region ;  no  case  attended  with  success  has,  so  far  as 
I  can  ascertain,  been  recorded. 

Other  operative  measures  dealing  directly  with  the  disease 
are  internal  cesophagotomy,  and  cauterisation  or  excision  with 
the  scissors  when  the  disease  is  situated  high  up.  Morell  Mac- 
kenzie ■'  records  a  case  where  by  the  aid  of  the  oesophagoscope 
he  was  enabled  to  remove  projecting  masses  of  the  growth  and 
so  allow  of  the  passage  of  a  tube.  Internal  cesophagotomy  has 
been  performed  by  Schiltz.''  In  one  case  the  patient  was 
oiven  great  relief.  The  operation  was  repeated  three  times, 
but  no  improvement  occurred  after  the  last  trial.     At  the  post 

1  Arcldvfur  Kim.  Chir.  1872,  Bd.  xiii.  p.  66. 

2  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  97. 

=  Journal  of  Laryngology  and  Rhinology,  1891,  vol.  v.  p.  208. 
*  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  iv.  G— 38. 
5  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  94. 
»  Berliner  Kiln.  Wochenschrift,  I8«2,p.  764. 


CARCINOMA  81 

mortem  it  was  found  that  a  tumour  was  situated  at  the  seat 
of  obstruction,  and  that  the  parts  failed  to  gape  after  the  last 
incision.  It  is  doubtful  whether  the  operation  should  ever  be 
attempted  for  cases  of  obstruction  due  to  carcinoma.  It  rarely 
happens  that  a  sufficient  amount  of  dilatation  cannot  be 
obtained  by  the  passage  of  bougies,  and  as  no  permanent 
good  effects  can  be  expected,  there  seems  little  justification  in 
attempting  a  measure  which  is  not  altogether  free  from  im- 
mediate danger. 

The  two  operations  worthy  most  consideration  are  those 
of  cesophagostomy  and  gastrostomy.  Both  have  the  same 
object  in  view,  to  obtain  an  artificial  entrance  into  the  stomach 
for  the  administration  of  nourishment.  The  former  operation 
is  performed  when  the  disease  is  located  high  up,  and  the  open- 
ing in  the  oesophagus  being  thus  below  the  seat  of  obstruction, 
a  feeding  tube  can  be  easily  passed  from  the  wound  into  the 
stomach.  Occasionally  the  oesophagus  is  opened  above  the 
level  of  the  disease,  the  object  then  being  to  facilitate  the 
passage  of  a  tube  which  otherwise  would  be  conducted  with 
pain  or  difficulty  through  the  natural  orifices. 

The  operation  of  gastrostomy  is  by  far  the  more  frequently 
adopted  measure,  and  considerable  differences  of  opinion  exist 
among  surgeons  as  to  the  period  when  it  should  be  performed. 
As  already  indicated,  permanent  tubage  has  to  some  extent 
replaced  this  operation,  and  those  who  practise  this  more  con- 
servative measure  do  not  consider  the  question  of  opening 
the  stomach  till  the  latest  stage  of  the  disease.  On  the  other 
hand,  those  who  advocate  gastrostomy  do  so  at  a  much  earlier 
stage.  Although  at  any  time  the  risks  of  the  operation  are 
grave,  they  are  nevertheless  materially  diminished  when  the 
patient  is  not  very  much  reduced  in  strength.  Therefore,  when 
performed  early  and  with  all  proper  precautions,  a  reasonable 
amount  of  success  may  be  expected.  David  Newman  '  records 
four  consecutive  successful  cases.  Contrasting,  however,  the 
operation  successfully  performed  with  the  alternative  of  per- 
manent tubage,  it  must  be  confessed  that  in  the  majority  of 
instances  the  patient  with  a  tube  in  the  oesophagus  is,  in 
various  ways,  in  a  more  comfortable  position  than  one  with  an 
artificial  orifice  in  the  stomach. 

'  Lancet,  1892,  vol.  i.  p.  7. 


THE   (ESOPHAGUS 


Case   XXXV. — Carcinoma   of  tlie  oesophagtis  :  gastrostomy  : 
survival  for  407  days. 

W.  0.,  aged  45,  had  for  four  years  siiffered  from  'indigestion,'  and  for 
thirteen  weeks  had  been  unable  to  take  any  sohd  food.  The  difficulty  in 
getting  food  down  had  steadily  increased,  and  for  two  days  everything 
taken  had  '  come  up  again.'  He  had  suffered  acutely  from  hunger  for 
some  days.  He  was  much  emaciated  (from  weighing  10  st.  he  was 
reduced  to  7  st.),  but  was  fairly  strong  and  had  no  physical  signs 
of  disease  other  than  an  obstruction  at  the  lower  end  of  the  oesophagus, 
which  was  discovered  by  the  passage  of  a  bougie.  Water  and  milk 
returned  at  once  when  he  attempted  to  take  them. 

Operation. — The  first  stage  of  gastrostomy  was  performed  on  Octo- 
ber 27,  1890,  strength  being  maintained  by  warmth,  rest,  and  nutrient 
enemata.  The  cardiac  end  of  the  stomach  and  its  anterior  wall  were 
extensively  infiltrated  by  malignant  growth.  On  October  30,  three  days 
afterwards,  the  operation  was  completed  by  opening  the  stomach,  and  the 
patient  was  fed  for  the  first  time.  A  week  after  the  operation  he  sat  up 
and  dressed,  having  suffered  neither  pain  nor  constitutional  disturbance  ; 
he  was  still  very  hxmgry.  A  wineglassful  of  whisky,  a  pint  of  milk,  and 
a  raw  egg,  administered  by  the  opening  through  a  tube  and  fimnel,  relieved 
the  feeling  of  hunger,  which  never  returned  in  the  same  aggravated  form 
again.  He  went  home  on  November  13.  Six  months  after  the  operation 
he  had  gained  1  st.  14  lbs.  in  weight.  In  May  he  went  to  his  work  as 
a  tailor,  and  'felt  better  and  lightsomer  than  he  had  done  any  time 
the  last  three  years.'  The  gastric  fistula  did  not  leak,  and  occasioned 
no  trouble  except  at  the  moment  of  withdrawing  the  tube,  when  fluids 
would  escape  without  care.  From  May  till  August  1891  he  worked  as  a 
tailor,  when  he  had  to  give  up  on  account  of  a  cough.  On  December  8, 
1891,  he  died,  apparently  from  infiltration  of  the  lungs  by  the  malignant 
growth.  No  post  mortem  could  be  obtained.  (Rutherford  Morison, '  Brit. 
Med.  Journ.'  1892,  vol.  i.  p.  963.) 

Sarcoma. — Except  as  pathologically  distinguished  from  car- 
cinoma, sarcoma  has  no  particular  clinical  features  peculiar  to 
it.  The  few  cases  of  the  disease  that  have  been  recorded 
were  mostly  mistaken  during  life  for  carcinonia,  and  it  has 
been  only  after  death  and  as  the  result  of  careful  microscopical 
examination  that  the  true  nature  of  the  disease  has  been  dis- 
covered. 

So  few  are  the  instances  recorded  that  almost  every  text- 
book dealing  at  any  length  with  diseases  of  the  oesophagus 
refers  back  to  the  same  cases.  Hence  Eosenbach's  ^  and 
Chapman's^   are   universally  quoted.      The   latter's    case,  I 

'   Berliner  Klin.  Wochenschrift,  1875,  vol.  xii.  p.  519. 

2  American  Journal  of  the  Medical  Sciences,  1887,  N.S.  vol.  Ixxiv.  p.  433. 


SARUUMA  83 

venture  to  think,  is  not  altogether  free  from  question.  The 
patient,  a  woman  aged  45,  had  suffered  from  dysphagia  for 
seven  months  prior  to  her  death.  Her  symptoms  were  those 
usually  present  in  carcinoma,  and  the  examination  with  the 
microscope  of  the  material  '  hawked '  up  did  not  apparently 
suggest  any  other  opinion.  After  death  the  diagnosis  of  sar- 
coma seems  to  have  heen  based  solely  upon  macroscopical 
appearances,  as  no  positive  statement  is  made  that  the  diseased 
part  was  examined  microscopically.  One  of  the  most  un- 
equivocal examples  of  sarcoma  of  the  oesophagus  was  shown  at 
the  Pathological  Society  of  London  by  Lauriston  Shaw.^  The 
specimen  was  that  of  an  ulcer  involving  the  upper  part  of  the 
CBsophagus  for  a,bout  three  inches,  its  limit  above  being  a  point 
about  an  inch  below  the  cricoid  cartilage.  The  ulcer  had  well- 
defined  edges  and  encircled  the  gullet.  Perforation  had  taken 
place  into  the  trachea.  The  patient  from  whom  the  specimen 
was  removed  was  a  female  aged  88.  She  had  suffered  from 
dysphagia  for  six  months,  and  died  one  week  after  admission 
into  the  hospital.  The  specimen  was  submitted  to  a  committee 
of  the  society,  which  corroborated  in  its  report  the  original 
statement  that  the  growth  was  a  sarcoma  consisting  of  round 
and  oval  cells.  At  the  same  society,  two  years  earlier,  Targett  ^ 
showed  a  specimen  of  a  sarcoma  taken  from  a  man  aged  70 
years  who  had  suffered  from  dysphagia  for  the  last  three 
months  of  his  life.  The  symptoms  present  were  those  usually 
observed  in  carcinoma.  The  tumour  found  at  the  autopsy  was 
attached  to  the  anterior  wall  of  the  gullet,  and  in  the  recent 
state  measured  four  and  a  half  inches  in  length  by  two  and  a 
half  inches  in  breadth,  and  about  an  inch  and  a  half  in  thick- 
ness. Its  upper  border  was  opposite  the  bifurcation  of  the 
trachea,  and  below  it  reached  very  nearly  to  the  cardia.  It 
was  somewhat  constricted  at  its  attachment,  and  found  to  take 
its  origin  from  the  submucous  coat.  The  free  surface  of  the 
tumour  was  in  a  state  of  ulceration  and  sloughing.  In  con- 
sistency it  was  firm,  and  resembled  somewhat  encephaloid  car- 
cinoma. Microscopically  it  was  seen  to  be  composed  of  round, 
oval,  spindle,  and  tailed  cells,  without  any  appearance  of  a 

•   Trans.  Path,  Soc.  Lond.  1891,  vol.  xlii.  p.  90. 
-  Ibid.  1889,  vol.  Ix.  p.  76. 


84  THE    (ESOPHAGUS 

stroma.  H.  D.  Eolleston '  records  a  case  of  round-celled 
sarcoma.  Secondary  growths  were  found  to  involve  many  ribs, 
the  right  iliac  bone  and  the  middle  fossa  of  the  skull.  The 
primary  growth  involved  the  lower  three  inches  of  the  gullet, 
thickening  it  so  as  to  cause  considerable  constriction. 

A  case  of  lympho-sarcoma  of  the  gullet  in  a  boy  4  years 
old  is  reported  by  Ste.phan.^  There  had  been  dysphagia,  pain 
in  swallowing,  and  vomiting.  The  patient  died  under  in- 
creasing oedema  and  repeated  paroxysms  of  dyspnoea.  At  the 
autopsy  a  tumour  was  found  close  to  the  cardia  measuring 
five-eighths  of  an  inch  in  length  and  three-eighths  of  an  inch 
in  thickness.  The  oesophagus  admitted  the  passage  of  a 
moderately  sized  catheter. 

Little  can  be  said  or  need  be  said  regarding  the  symptoms 
of  sarcoma  of  the  oesophagus.  When  it  is  remembered  how 
in  their  pathological  aspects  both  carcinoma  and  sarcoma 
resemble  each  other,  how  both  in  their  progress  tend  towards 
growth  and  destruction,  it  will  be  understood  that  what  is  said  of 
one  could  equally  be  said  of  the  other.  Hence  we  may  expect 
that  sarcoma  attacking  the  gullet  will  produce  symptoms  pre- 
cisely similar  to  such  as  arise  in  carcinoma ;  and  such  few  cases 
as  are  recorded  tend  to  show  the  truth  of  the  supposition. 


CHAPTER   IX 

NON-MALIGNANT    OR   CICATRICIAL    STRICTURE 

The  stenosis  which  follows  from  malignant  disease,  and  which 
has  just  been  discussed,  differs  in  two  important  particulars 
from  the  affection  now  to  be  dealt  with.  In  the  former  instance 
the  contraction  of  the  canal  is  associated  with  progressive 
growth  and  destruction  of  tissue,  while  in  the  latter  the  sole 
pathological  feature  is  the  cicatricial  contraction.  Another 
point  of  distinction  rests  in  the  nature  of  the  cause.  While 
in  malignant  disease  we  are  ignorant  of  what  is  the  origin  of 
the  process  which  leads  to  obstruction,  in  the  case  of  purely 

'   Trans.  Path.  Soc.  Lond.  1893,  vol.  xliv.  p.  65. 

2  Solis-Cohen,  Anntcal  of  the    Universal  Medical  Sciences,  1892,  vol.  iv. 
F-B3. 


CICATKUHAL    tSTUiCTUlIE  85 

cicatricial   stricture  wc  know  it  to  be  due  to  some  definite 
influence. 

Etiology. — Many  of  the  causes  which  give  rise  to  cicatricial 
contraction  have  already  been  alluded  to,  but  the  subject  of 
stricture  was  only  briefly  indicated  as  a  possible  sequel  to  the 
affection.  The  causes  already  described  are  traumatism, 
chronic  asophagitis,  simple  ulcer,  syphilis,  and  tuberculosis. 
To  these  may  be  added  such  rarer  causes  as  smallpox,  repeated 
attacks  of  vomiting,  the  suppression  of  certain  discharges  or 
skin  eruptions,  prolonged  spasm,  and  possibly  rheumatism 
and  gout. 

Stenosis  from  traumatism. — In  various  ways  injuries  to  the 
oesophagus,  received  externally  or  internally,  may  lead  to 
stricture.  Thus  it  may  be  as  the  result  of  chronic  inflammation : 
of  destruction  of  tissue  at  the  time  of  the  accident ;  or  of  ulcera- 
tion taking  place  subsequently.  By  far  the  most  frequent  cause 
is  that  which  results  from  ulceration.  This  is  usually  effected 
in  one  of  two  ways.  Either  it  is  due  to  prolonged  impaction 
of  a  foreign  body  such  as  a  bone,  a  fruit  stone,  or  other  such 
sharp  and  irregularly  shaped  bodies,  or,  as  is  more  frequently 
the  case,  it  results  from  swallowing  some  caustic  alkali  or  acid. 

Ulceration  which  results  from  an  impacted  body  is  of  course 
limited  to  the  seat  of  impaction.  The  depth  and  superficial 
extent  of  the  process  vary  according  to  the  size  and  general 
nature  of  the  impacted  body.  The  form  of  stricture  which 
results  will  similarly  be  limited.  The  exception  in  this  class 
of  cases  is  where  endeavours  at  extraction,  whether  successful 
or  otherwise,  have  led  to  injuries  of  other  parts  of  the  oeso- 
phagus ;  so  that  instead  of  one  stricture  two  or  more  may  be 
met  with.  Thus  Morejon  ^  has  recorded  the  case  of  a  patient 
aged  23  who,  when  8  years  old,  swallowed  a  large  needle. 
Efforts  at  withdrawal  led  to  injury  of  tiie  walls  of  the  gullet 
at  another  spot,  so  that  two  strictures  were  found  to  exist,  one 
at  the  level  of  the  diaphragmatic  ring  and  another  opposite 
the  first  dorsal  vertebra. 

Strictures  which  result  from  swallowing  acids,  caustic 
alkalis,  or  boiling  fluids  may  be  single,  but  are  not  infrequently 
multiple  ;  and  even  when  single  they  are  usually  much  more 
extensive  and  much  more  irregular  than  those  following  other 

'  Journal  of  Laryngology  and  Ehinology,  1890  vol.  iv.  p.  19. 


86  THE   (ESOPHAGUS 

forms  of  traumatism.  When  it  is  remembered  how  all  parts 
of  the  canal  are  subjected  to  the  cauterising  influence  of  the 
fluid,  it  will  at  once  be  gathered  how  extensive  may  be  the 
destruction  of  tissue  and  subsequent  ulceration,  and  how 
irregular  its  distribution.  There  are,  however,  parts  more 
frequently  and  more  severely  attached  than  others.  These 
are  the  more  constricted  and  rigid  portions  of  the  canal,  such 
as  opposite  the  bifurcation  of  the  trachea,  at  its  commence- 
ment near  the  cricoid  cartilage,  and  at  its  termination  near 
the  cardia.  The  following  table  of  twelve  cases  compiled  by 
Weinlechner,'  where  the  seat  of  stricture  was  accurately 
determined  at  the  post  mortem,  are  also  interesting  as  show- 
ing the  extent  and  number  of  strictures  which  may  be  present. 

In  8  cases  the  thoracic  part  was  alone  hnphcated. 

In  1  case  there  were  three  strictures. 

,,  2  cases  there  were  two  strictures. 

,,  5  cases  there  was  one  stricture. 
In  2  cases  both  thoracic  and  cervical  regions  were  implicated. 

In  1  the  cervical  stricture  was  opposite  the  cricoid. 

„    ,,    „  ,,  „  ,,    4  cm.  below  the  cricoid. 

In  1  case  the  cervical  part  was  alone  involved. 
In  1  case  the  entire  oesophagus  was  moderately  affected. 
12 

A  case  somewhat  similar  to  the  last  of  Weinlechner's, 
only  more  severe,  has  been  recorded  by  Mackenzie.^  In  this 
instance  the  oesophagus  was  bound  to  the  prevertebral  muscles 
by  bands  of  dense  fibrous  tissue,  rendering  its  separation  from 
the  surrounding  parts  very  difficult.  Barely  half  an  inch 
below  the  cricoid  cartilage  the  stricture  commenced,  and 
extended  downwards  to  within  an  inch  of  the  cardia.  The 
walls  of  the  gullet  throughout  the  whole  of  the  strictured  por- 
tion were  enormously  thickened,  the  cut  edge  in  some  places 
being  one-eighth  of  an  inch  deep  and  very  tough.  The 
narrowest  part  of  the  stricture  was  situated  above  and  con- 
sisted of  four  longitudinal  ridges. 

Stenosis  from  chronic  cesophag-itis. — Eare  as  is  chronic 
oesophagitis,  still  rarer  is  the  sequel  to  it — stenosis.  The 
kind  of  stricture  which  results  from  this  afi'ection  resembles 
that  which  follows  on  chronic  urethritis.     The  inflammatory 

'   Wiener  Med.  Wochcnschrift,  1880,  p.  33. 

2  American  Journal  of  the  Medical  Sciences,  1883,  N.S.  vol.  Ixxxv.  p.  436. 


CICATRICIAL    STRICTUKE  87 

process  leads  to  a  thickening  of  the  mucous  membrane  and 
submucous  tissue,  with  changes  extending  sometimes  into  the 
muscular  coat.  The  parts  thus  thickened  by  infiltration  and 
new-formed  tissue  contract  and  lead  to  a  narrowing  of  the 
canal. 

Stenosis  from  simple  ulcer. — The  variet}'  in  form  of  this 
kind  of  ulcer  naturally'  entails  a  corresponding  variety  in  the 
strictures  resulting  from  it  ;  thus  a  cicatricial  ring  may  be 
produced,  or  simply  a  fibrous  band  coursing  for  a  variable  ex- 
tent transversely  or  in  some  other  direction.  Debove's  '  case 
already  quoted  may  be  instanced  in  illustration.  The  diagnosis 
made  during  the  life  of  the  patient  was  corroborated  at  the 
post  mortem  two  years  later.  It  was  then  found  that  a 
cicatricial  fibrous  band  existed  at  a  distance  of  two  inches  from 
the  cardia,  and  that  an  ulcer  also  was  seated  in  the  stomach 
near  its  lesser  curvature. 

Stenosis  due  to  syphilis. — Within  recent  years  numerous 
cases  have  been  recorded  of  stricture  of  the  oesophagus  due  to 
syphilis.  Inasmuch  as  gummata''^  have  been  found  in  the 
lining  wall  of  the  gullet,  it  is  only  reasonable  to  suppose  that, 
as  in  other  parts  of  the  body,  they  may  break  down  and  give 
rise  to  ulceration,  which  in  the  process  of  healing  will  lead  to 
stricture.  Sj^philitic  stenosis  of  the  oesophagus  has  been  dealt 
with  at  considerable  length  in  a  paper  by  Lubinski,^  who  also 
refers  to  numerous  other  instances  of  the  affection. 

There  is  little  that  can  be  said  to  be  specially  characteristic 
of  this  kind  of  stenosis.  In  almost  all  instances  the  diagnosis 
of  the  cause  has  rested  either  upon  an  unmistakable  history 
of  syphilis  some  years  previously,  or  the  existing  evidence  of 
such  an  attack  in  lesions  in  other  parts  of  the  body.  A  case 
is  recorded  l)y  Kempe,'*  where  there  was  a  tight  stricture  about 
four  inches  down.  The  patient  had  extensive  destruction  of 
the  hard  and  soft  palate,  uvula,  &c.,  and  a  deep  sloughy  pre- 
vertebral ulcer  on  the  posterior  wall  of  the  pharynx.  In  a 
case  of  Potain's '"'  the  diagnosis  was  based  upon  the  presence 

'  See  above,  page  48. 

^  Wilks  and  Moxon,  Anatomical  Pathology,  2nd  edit.  p.  366. 

^  Berliner  Klin.  Wochenschrif  t,  188d,  \6l.  xx.  p.  501. 

*  Brit.  Med.  Journ.  1890,  vol.  ii.  p.  1480. 

'  Journal  of  Laryngology  and  Rhinology,  1887,  vol.  i.  p.  412. 


88  THE    (ESOPHAGUS 

of  paralysis  of  the  motor  oculi  muscles  and  the  absence  of 
symptoms  suggestive  of  any  other  cause.  In  two  of  Lubinski's 
cases,  contained  in  his  paper  above  alluded  to,  there  was  a 
well-marked  history  of  syphilis  of  some  years'  duration,  with, 
in  addition,  in  the  one  case,  a  small  scar  on  the  uvula, 
and  in  the  other  a  gumma  on  the  tongue.  The  age  of 
the  first  patient  was  29  years,  and  that  of  the  second  64 
years.  In  both,  also,  the  diagnosis  was  assisted  by  the 
absence  of  the  symptoms  suggestive  of  any  other  cause,  and 
it  was  subsequently  confirmed  by  the  amenability  of  the  stric- 
ture to  the  influence  of  iodide  of  potassium  and  the  j)assage  of 
bougies. 

Case  XXXVI. — Sypliilitic  stenosis  of  the  oesophagus. 
A  man  aged  29  years  was  admitted  to  the  University  Poliklinik  with 
difficulty  in  swallowing  solid  food.  His  trouble  had  existed  for  three 
weeks.  He  denied  having  swallowed  at  any  time  caustic  fluids  or  a  foreign 
body.  On  examination  of  the  throat  a  cicatrix  was  seen  in  the  uvula 
which  caused  it  to  deviate  to  the  right.  A  medium  sized  sound  passed 
easily  as  far  as  the  sixth  dorsal  vertebra,  but  any  farther  progress  was 
checked.  A  moderately  fine  bougie  could,  however,  be  passed.  Auscul- 
tation about  this  part  revealed  a  loud  splashing  noise  followed  by  a  slight 
regurgitation,  when,  after  a  few  seconds,  the  material  passed  into  the 
stomach  with  a  '  cooing  sound.'  The  possibility  of  malignant  disease  was 
excluded  owing  to  the  age  of  the  patient  and  the  absence  of  any  cachectic 
signs.  The  man  stated  that  ten  years  before  he  had  had  a  sore  on  his 
penis,  followed  by  a  rash  and  sore  throat.  These  symptoms  disappeared 
under  treatment  at  the  time.  The  existence  therefore  of  the  cicatrix  on 
the  uvula,  the  history  of  syphilitic  infection,  the  absence  of  any  evidence 
suggestive  of  other  causes,  led  to  the  opinion  that  the  stricture  was 
syphilitic.  Iodide  of  potassium  was  administered  and  bougies  passed. 
The  patient  ultimately  recovered.  (Liibinski,  'Berliner  Klin.  Wochen- 
schrift,'  1883,  p.  501.) 

Stenosis  from  tuberculosis,  &c. — Stenosis  arising  from  other 
causes  than  those  just  described  is  so  extremely  rare  that  it 
needs  little  more  than  a  passing  notice. 

Konrad  Zenker  ^  records  an  example  of  stricture  from 
tuberculosis.  It  occurred  in  a  patient  aged  38  years, 
who  for  four  years  had  suffered  from  repeated  attacks  of 
violent  haemoptysis.  For  about  two  m.onths  there  had  been 
increasing  difficulty  in  swallowing.  A  stricture  was  detected 
opposite  the  cricoid  cartilage.     After  the  death  of  the  patient 

'  Deutschcs  Archiv  filr  Klin.  Med.  1895,  Bd.  Iv.  p.  414. 


CICATRICIAL    STRICTURE  89 

a  superficial  ulcer  was  found,  the  base  of  which  consisted  of 
cicatricial  tissue  surrounding  the  entire  circumference  of  the 
canal.  A  microscopical  examination  of  the  ulcer  and  sur- 
rounding parts  revealed  the  typical  structure  of  tubercle  and 
the  presence  of  tubercular  bacilli. 

Voigt '  records  the  case  of  a  woman  in  whom  stricture 
followed  upon  repeated  vomitings  during  her  first  and  only 
pregnancy.  The  history  of  the  case,  however,  it  was  thought, 
pointed  rather  to  some  slight  rupture  or  laceration  during  one 
of  the  attacks. 

A  somewhat  unusual  form  of  stricture  is  described  by 
Audry.^  Two  cases  are  reported  which  were  supposed  during 
life  to  have  been  cancerous.  They  were  discovered,  however, 
by  histological  examination  to  be  due  to  simple  hyperplasia  of 
the  muscular  coat. 

Occasionally  cases  occur  where  no  cause  can  be  ascribed ; 
the  symptoms  have  come  on  insidiously,  and  finally  there  is 
well-marked  evidence  of  a  cicatricial  stenosis.  In  some  of 
these  cases  the  patients  have  been  subjects  of  rheumatism  or 
gout,^ 

Under  the  heading  of  '  Simple  Stenosis '  cases  have  been 
recorded  where  it  was  found  that  the  stricture  consisted  in  a 
localised  narrowing  of  the  mucous  and  submucous  lining  of 
the  canal,  without  any  evidence  of  traumatism  or  cicatricial 
tissue.  Franks  ^  reports  such  a  case  and  refers  to  nine  others. 
In  this  particular  case  the  author  successfully  excised  the 
narrowed  part,  leaving,  however,  the  unaffected  muscle  wall 
untouched. 

Symptoms. — The  symptoms  of  stricture  of  the  oesophagus 
dependent  upon  any  of  the  causes  above  mentioned  are  almost 
solely  connected  with  progressive  dysphagia.  At  first  there 
is  the  difiiculty  of  swallowing  solids.  The  patient  finds  it 
necessary  to  moisten  the  food  with  fluid,  or  after  each  effort 
at  deglutition  to  swallow  a  mouthful  of  liquid  to  make  the 
bolus  go  down.  As  the  canal  narrows  solids  can  no  longer  be 
taken  and  only  liquids  will  pass,  till  finally  in  the  severest 

'  Medical  and  Surgical  Reporter,  1883,  vol.  xlviii.  p.  45. 
-'  Journal  of  Laryngology  and  Illiinology,  vol.  ii.  p.  241. 
•'  Ingals,  Neio  York  Medical  Record,  1890,  vol.  i.  p.  1. 
'  Brit.  Med.  Journ.  1894,  vol.  ii.  p.  973. 


90  THE   (ESOPHAGUS 

cases  nothing  can  be  got  into  the  stomach  past  the  constriction. 
Concomitant  with  the  difficulty  in  deglutition  is  the  occasional 
return  of  the  food  by  the  mouth.  The  patient  vomits  at  vari- 
able intervals  of  time  after  taking  something  that  will  not 
pass  through  the  stricture.  If  the  stricture  is  situated  high 
up,  vomiting  takes  place  almost  immediately ;  while  if  lower 
down,  and  especially  if  associated  with  some  dilatation  of  the 
canal  above,  the  return  is  delayed.  Independently  of  taking 
food,  the  patient  occasionally  '  hawks '  up  quantities  of  clear 
viscid  material,  which  is  saliva  that  has  been  swallowed 
mixed  with  the  mucoid  secretion  from  the  lining  membrane 
of  the  oesophagus,  both  having  collected  and  lodged  above  the 
seat  of  obstruction.  The  gradual  diminution  in  the  amount 
of  food  taken  into  the  stomach  leads  to  progressive  emaciation, 
with,  in  the  earlier  stage,  the  painful  feeling  of  hunger,  and 
in.  the  later,  that  of  increasing  weakness.  Pain,  not  extending 
beyond  a  feeling  of  discomfort  in  some  cases,  is  usually  ex- 
perienced in  the  region  of  the  stricture,  and  felt  either  about 
the  epigastrium,  behind  the  sternum,  or  between  the  shoulder 
blades.  Occasionally  the  pain  is  referred  to  more  distant  parts. 
The  smallness  in  quantity  of  the  food  which  enters  the  stomach 
causes  gastric  disturbances  and  troublesome  constipation. 

DifFerential  diagnosis. — The  differentiation  of  the  symptoms 
of  obstruction  due  to  cicatricial  stricture  of  the  oesophagus  from 
those  dependent  upon  malignant  disease,  upon  spasmodic  affec- 
tions, and  upon  external  pressure,  will  mostly  depend  upon  the 
relative  distinctness  of  the  other  associated  symptoms.  The  age 
and  sex  of  the  patient,  in  the  absence  of  any  history  of  trauma- 
tism or  syphilis,  will  reasonably  suggest  that  symptoms  of  ob- 
struction in  a  man  over  40  years  of  age  are  due  to  malignant 
disease  ;  and,  further,  the  presence  of  any  blood  either  in  the 
ejecta,  or  on  the  bougie  after  its  use,  will  tend  to  corroborate 
the  opinion.  The  mere  passage  of  a  bougie  will  also  serve  in 
many  cases  to  eliminate  obstruction  due  to  spasm  and  pres- 
sure from  without.  The  instrument  being  passed  when  the 
patient  is  under  the  influence  of  an  anaesthetic,  there  will  be 
an  absence  of  any  sensation  of  '  grip '  such  as  is  experienced 
in  a  purely  cicatricial  stricture.  Where  obstruction  is  due  to 
pressure  from  without,  such  for  instance  as  occurs  in  some 
cases  of  aneurysm,  there  will  probably  exist  other  symptoms 


CICATRICIAL   STRICTUKE  91 

peculiar  to  the  disease  itself.  Cases  will  occur  where  the 
symptoms  at  the  time  are  not  sufficiently  distinctive  to 
admit  of  a  definil-e  diagnosis  being  made.  The  progress  of 
the  case  will,  however,  tend  sooner  or  later  to  clear  up  any 
obscurity. 

Diagnosis. — To  determine  the  cause  of  the  stricture,  its 
seat,  and  particular  nature,  are  all  points  of  considerable  im- 
portance in  connection  with  the  proper  treatment  of  the  case. 
The  history  of  the  case  should  in  most  cases  lead  to  a  correct 
diagnosis  of  its  cause.  Thus  no  difficulty  will  arise  in  this 
respect  when  a  history  of  swallowing  some  caustic  fluid  is 
obtained,  or  when  there  exist  about  the  body  secondary  or 
tertiary  scars  the  result  of  some  previous  attack  of  syphilis. 
Again,  the  history  of  a  foreign  body  impacted  for  some  time, 
and  any  difficulty  connected  with  its  extraction,  will  leave 
little  doubt  as  to  traumatic  origin.  Strictures  due  to 
other  simple  causes  will  not  be  so  easy  to  determine. 
Previous  moderate  attacks  of  hsemorrhage  might  correctly 
indicate  simple  ulcer.  Debove's  ^  case  already  quoted  is  an 
illastration  of  this.  The  rarer  causes  which  have  been  given, 
such  as  chronic  oesophagitis,  tuberculosis,  &c.,  can,  as  a  rule, 
only  be  matter  of  conjecture. 

The  value  of  knowing  the  cause  of  the  stricture  rests 
upon  the  light  that  is  thrown  upon  its  nature.  Thus  the 
stricture  which  results  from  swallowing  some  caustic  fluid 
will  be  probably  irregular,  possibly  multiple,  and  located 
usually  either  in  the  region  of  the  cricoid  cartilage,  opposite 
the  bifurcation  of  the  trachea,  or  near  the  cardia.  Stric- 
tures, on  the  other  hand,  which  result  from  an  impacted 
foreign  body,  a  simple  ulcer,  or  syphilis,  will  be  single,  possibly 
involving  only  a  part  of  the  circumference  of  the  canal,  and 
consist  in  longitudinal,  oblique,  or  transverse  fibrous  bands. 
When  a  sound  can  be  passed,  some  of  the  opinions  formed 
from  a  knowledge  of  the  cause  may  be  corroborated  or 
possibly  extended.  Thus,  by  using  a  sound  with  an  olive- 
shaped  ivory  or  metal  end,  the  '  olive '  will  detect,  both  in  its 
progress  inwards  and  in  its  withdrawal,  whether  there  is  more 
than  one  stricture,  the  probable  length  of  a  stricture,  and  its 

'   See  above,  page  48. 


92  THE   CESOPIIAGUS 

calibre  and  tightness.  In  a  case  reported  by  H.  L.  Browne,' 
the  author  by  this  method  of  examination  was  enabled  to 
detect  five  distinct  strictures.  Where  there  is  reason  to 
suspect  a  bridle  stricture,  hemispherical-headed  sounds  have 
been  used  to  discover  on  which  aspect  of  the  wall  the  stricture 
is  situated.  By  rotation  of  the  head  it  is  felt  on  which  side 
the  '  hitch  '  takes  place. 

Prognosis. — The  final  termination  of  any  case  will  depend 
largely  upon  the  cause  which  has  led  to  the  stenosis.  It  has 
already  been  shown  that  the  nature  of  the  stricture  varies 
considerably  with  the  cause.  The  worst  form  is  that  which 
follows  upon  the  imbibition  of  some  caustic  fluid ;  and  it  may 
be  said  that  the  sooner  the  symptoms  of  obstruction  arise  after 
the  subsidence  of  those  which  follow  the  immediate  injury, 
the  worse  is  likely  to  be  the  stricture.  In  this  class  of  cases 
almost  the  only  hope  of  a  successful  issue  rests  in  the  possi- 
bility of  dilating  the  stricture  simply,  or  by  some  operative 
means,  and  keeping  it  dilated ;  otherwise  death  by  gradual 
starvation  must  be  expected.  Such  cicatricial  strictures  as 
arise  from  ulcers  resulting  from  an  impacted  hody,  syphilis, 
tuberculosis,  &c.  are  mostly  dealt  with  successfully. 

The  want  of  accurate  knowledge  regarding  the  nature  of  a 
stricture  in  all  its  aspects  must  always  render  any  positive 
prognosis  very  difficult,  if  not  impossible.  Thus  it  is  always 
possible  that  cicatrisation  may  not  be  circular,  only  '  island- 
like '—to  borrow  an  expression  of  Weinlechner's.  In  such  a 
case  the  canal  will  contract  to  a  certain  extent  and  remain  so, 
the  patient  being  able  to  swallow  fluids  but  incapable  of 
taking  solids.  Of  such  a  nature  appears  to  have  been  the  case 
recorded  by  Harvey.^  A  man  aged  46  years  stated  that 
when  5  years  old  he  had  swallowed  some  strong  sulphuric 
acid.  For  forty  years  his  throat  had  been  almost  closed, 
and  he  had  lived  on  milk,  beef  tea,  eggs,  and  cornflour. 

Prognosis  in  regard  to  treatment  even  in  its  simplest  form, 
such  as  consists  in  the  passage  of  a  bougie,  must  be  somewhat 
guarded.  Weinlechner  ^  gives  seven  cases  where  after  attempts 
to  pass  a  bougie  a  rapidly  fatal  result  ensued.      The  post 

'  Birmingham  Medical  Revieiu,  1890,  vol.  xxvii.  p.  89. 

•^  Ibid.  1889,  vol.  xxvi.  p.  225. 

°  Wiener  Med.  Wochenschrift,  1880,  p.  113. 


CICATIMCIAL    STKK'TUllE  93 

mortem  revealed  no  gross  lesion.  In  three  cases  death  resulted 
from  pyo-pneumothorax,  and  in  four  from  empyema.  Billroth, 
in  commenting  on  these  cases,  believes  that  septic  matter  was 
carried  at  some  time  by  the  bougie  through  the  wall  of  the 
cesophagus  into  its  surrounding  cellular  tissue,  and  there  soon 
gave  rise  to  an  acute  inflammation.  What  success,  on  the 
other  hand,  may  follow  this  mode  of  treatment  is  instanced 
by  the  same  author  in  a  case  which  he  recalls  where,  ten  years 
after  passing  the  bougie,  there  was  not  the  least  difficulty  in 
swallowing.  The  apparently  simple  operation  of  internal  oeso- 
phagotomy  is  not  free  from  untoward  results.  Thus  Sands  ^ 
mentions  several  cases  where  accidents  have  happened.  In 
two  cases  peritonitis  was  set  up,  the  result  possibly  of  direct 
injury  to  the  stomach ;  in  two  others  haemorrhage,  and  in  one 
empyema. 

The  risks  in  connection  with  such  major  operations  as 
gastrostomy  need  not  be  further  considered.  Little  danger 
appears  to  be  connected  with  treatment  by  electrolysis. 


CHAPTEE   X 

CICATRICIAL     STRICTURE    {continued).     TREATMENT 

By  no  other  measures  than  those  which  may  be  said  to  be 
strictly  surgical  can  we  treat  cicatricial  stricture  of  the 
cesojDhagus.  Iodide  of  potassium  given  internally  will  aid  in 
syphilitic  cases,  but  with  this  exception  all  methods  of  treat- 
ment are  based  on  some  kind  of  mechanical  procedure. 

The  means  at  our  disposal  are — (1)  Gradual  dilatation, 
(2)  forcible  or  rapid  dilatation,  (3)  electrolysis,  (4)  internal 
cesophagotomy,  (5)  external  oesophagotomy,  (6)  oesophago- 
stomy,  (7)  gastrostomy. 

(1)  Gradual  Dilatation. — This  method  may  be  performed  in 
one  of  two  ways,  either  (A)  from  above  through  the  mouth,  or 
(B)  from  below  through  an  opening  in  the  stomach. 

(A)   Through  the  mouth. — Whatever   may  be  the  cause  of 

'  New  York  Med.  Journ.  1884,  vol.  xxxix.  p.  533. 


94  THE   CESOPHAGUS 

a  stricture,  and  whatever  its  form,  no  ease  will  escape  a 
preliminary  endeavour  being  made  to  treat  it  by  this  method. 
It  is  usually  owing  to  some  failure  in  attempts  made  to 
dilate  in  this  way  that  one  of  the  other  methods  is  resorted  to. 

As  in  cases  of  urethral  stricture,  it  is  wise  to  commence 
with  a  large-sized  bougie,  not  so  much  with  the  object  of 
passing  it,  but  in  ordjer  to  ascertain  the  exact  seat  of  obstruc- 
tion. This  knowledge  gained,  a  medium- sized  instrument 
may  then  be  tried.  If  with  the  most  careful  pressure  it  does  not 
enter,  an  instrument  of  some  two  or  three  sizes  smaller  should 
be  used.  Once  the  stricture  is  penetrated,  it  is  well,  if  the 
patient  can  bear  it,  to  retain  the  bougie  within  the  constric- 
tion for  some  minutes,  or  indeed  as  long  as  can  be  endured. 
Considerable  difference  of  opinion  exists  with  regard  to  the 
subsequent  treatment  of  the  case:  whether  a  bougie  should 
be  passed  daily  or  at  greater  intervals ;  whether  a  few  days 
should  be  spent  in  passing  the  same  instrument,  or  whether  a 
larger  size  should  be  attempted  on  each  occasion.  Kather 
than  lay  down  any  definite  rule,  it  would  be  wiser  to  be 
guided  by  the  nature  and  behaviour  of  the  case  itself.  If  a 
stricture  is  very  tight,  and  the  parts  are  very  sensitive  to 
the  passage  of  a  bougie,  the  progress  of  the  treatment  should 
be  slow  ;  and,  vice  versa,  the  more  tolerant  the  parts  and  the 
less  resistant  the  stricture,  the  more  frequent  may  be  the 
passage  of  the  instrument,  and  the  larger  its  size  at  each 
introduction.  In  a  case  of  gradual  dilatation  recorded  by 
K.  Franks,^  bougies  were  passed  almost  without  intermission 
every  second  day  for  seven  months,  and  retained  in  for  periods 
varying  from  ten  minutes  to  three  hours.  This  patient,  when 
last  seen,  had  been  quite  well  for  six  years.  Bougies  were 
passed  about  twice  annually. 

The  retention  of  a  bougie  in  a  stricture  tends  to  dilate  it, 
just  in  the  same  way  as  the  retention  of  a  catheter  in  a 
urethral  stricture.  Hence  a  good  plan  is  to  pass  a  tube  as 
soon  as  possible,  retain  it,  and  feed  the  patient  through  it.  A 
short  permanent  tube  has  been  employed  with  success. 
Symonds  ^  mentions  in  his  paper,  already  referred  to,  that 
when  in  Berlin,  be  saw  a  case  of  Eenvers's  being  treated 

'  Transactions  of  the  Royal  Academy  of  Medicine  in  Ireland,  1890,  vol.  viii. 
p.  213.  -  Lancet,  1889,  vol.  i.  p.  672. 


CICATRICIAL    STRICTURE  <,»r, 

successfully    by    the    specially    devised    short    hard    rubber 
permanent  tube  of  that  surgeon. 

Eve '  reported  a  case  to  the  Clinical  Society  of  London 
where  he  succeeded  in  first  introducing  a  No.  7  Symonds's 
tube  and  subsequently  a  No.  11.  In  attempting  to  withdraw 
the  latter,  the  string  to  which  it  was  attached  broke.  An 
OBSophagostomy  was  performed  for  its  extraction. 

No  case  should  be  deemed  intractable  to  this  the  simplest 
method  of  treatment,  until  several  endeavours  have  been  made 
at  variable  intervals  of  time.  After  the  first  failure,  the  patien*; 
should  be  kept  in  bed  and  the  most  careful  attention  devoted 
to  the  diet ;  and  if  the  condition  of  the  patient  will  admit,  the 
parts  should  be  kept  at  complete  rest,  by  the  administration 
of  all  food  ^jcr  rectum.  By  such  means  any  co  existent  s^Dasm 
may  be  relieved,  and  the  stricture  thereby  conquered.  (For 
directions  regarding  the  passing  of  bougies,  see  Operations  on 
the  (Esophagus,  Chapter  XVI.) 

(B)  Through  the  stomach. — This  mode  of  treatment  may  be 
adopted  in  those  cases  of  irregular  and  multiple  stricture,  the 
result  of  imbibing  some  caustic  fluid,  where  the  patient  can 
swallow  liquids,  but  no  bougie  can  be  passed  from  above. 
Gastrostomy  is  first  performed,  and  after  the  establishment  ef 
a  gastric  fistula,  the  patient  is  made  to  swallow  a  shot  to 
which  is  attached  a  silk  thread.  This  can  be  brought  out  by 
the  gastric  opening,  and  by  its  means  tubes  or  bougies  intro- 
duced and  gradual  dilatation  effected.  A  case  is  recorded  by 
Tietze^  of  a  boy  aged  16,  in  whom,  twelve  days  after  gastro- 
stom}^,  a  thread  was  passed  with  a  sound  through  the  whole 
length  of  the  oesophagus,  one  end  coming  out  through  the 
nose,  and  the  other  through  the  gastric  fistula.  A  drainage 
tube  was  eventually  passed  through  the  stricture  and  left. 
Dilatation  was  effected,  and  eventually  the  gastric  fistula  was 
allowed  to  close.  This  author  records  two  other  cases  where 
it  was  found  impossible  after  gastrostomy  to  effect  any  passage 
of  the  stricture.  In  both  instances  oesophagotomy  was  j)er- 
formed  in  addition.  It  was  then  found  possible  to  pass 
bougies  from    the   cesophageal  openmg,  and  thus  gradually 

1  Brit.  Med.  Journ.  1892,  vol.  ii.  p.  894. 
•-'  Ibid.  Epitome,  1894,  vol.  i.  p.  82. 


9«  THE   CESOPHAGUS 

dilate  the  stricture.  Tietze  prefers  gradual  dilatation  with  a 
drainage  tube  to  bougies. 

Terrillon  ^  records  a  case  in  which  he  succeeded  by  this 
method ;  gastrotomy,  however,  and  not  gastrostomy,  was 
performed,  the  opening  into  the  stomach  being  closed  after 
the  first  bougie  was  made  to  pass  from  above  downwards 
through  the  strictm^e.  Dixon  ^  succeeded  by  gradual  dilatation 
after  gastrostomy. 

(2)  Forcible  or  Rapid  Dilatation. — This  method  may  also  be 
performed  either  (A.)  from  above  through  the  mouth,  or  (B) 
from  below  through  an  opening  in  the  stomach. 

(A)  Through  the  mouth. — There  are  various  methods  by 
which  this  may  be  performed. 

(a)  With  ordinary  bougies. — In  adopting  these  means,  the 
same  procedure  is  made  use  of  as  in  the  rapid  dilatation  of  an 
urethral  stricture.  One  bougie  is  made  to  follow  the  other 
until  the  stricture  has  been  forcibly  stretched  or  burst  to  the 
required  extent. 

Case  XXXVTI. — Forcible  dilatation  of  cicatricial  stricture  luith 

bougies. 

A  boy  aged  12  years  had  three  strictures  in  the  oesophagus,  the  tightest 
being  near  the  cricoid  cartilage,  caused  by  swallowing  liquor  potassse. 
Dilatation  was  effected  gradually  until  a  No.  11  urethral  catheter-sized 
bougie  was  passed,  but  no  further  dilatation  could  be  effected.  A  special 
bougie  was  devised  by  which  more  force  could  be  used,  but  with  equal  safety. 
The  instrument  consisted  in  a  whalebone  bougie,  which  was  first  introduced, 
and  then  this  served  as  a  guide  for  the  gliding  along  of  the  specially 
devised  'olive-ended  sounds.'  By  this  means  a  soxnid  of  a- diameter  of 
three-quarters  of  an  inch  was  forced  through  the  stricture.  A  few  drops 
of  blood  were  coughed  up  and  a  little  pain  complained  of,  but  otherwise 
no  ill  effects  were  experienced.  When  seen  eighteen  months  later  the 
boy  could  swallow  perfectly.  (MacCormac,  '  Lancet,'  1886,  vol.  i.  p.  191. 
The  instrument  devised  and  used  by  this  surgeon  is  shown  by  a  drawing.) 

(&)  With  railway  catheters. — A  tube  with  terminal  openings 
is  passed  through  the  stricture.  Through  this  tube  is  inserted 
a  catgut  bougie.  The  tube  is  then  removed,  and  the  bougie 
used  as  a  guide  for  the  passage  of  catheters  of  increasing 
calibre.     James  Berry  ^  has  successfully  adopted  this  method 

1  Journal  of  Laryngology  and  Rliinology,  1890,  vol.  iv.  p.  159. 

2  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  iv.  F — 36. 

3  St.  Bartholomew'' s  Hosjntal  Reports,  1884,  vol.  xx.  p.  45. 


CrCATrvICIAL     STIMCTUHR  97 

in  two  cases.     He  found  also  that  the  catgut  guide  enabled 
him  to  pass  a  soft  rubber  tube. 

(c)  WitJt  sea  tangle,  tupelo-wood  dilators,  or  laminaria 
tents. — This  appears  a  useful  way  of  dilating  when  the  passage 
of  bougies  causes  much  pain  or  bleeding.  The  use  of  sea 
tangle  was  successfully  adopted  by  Whitla  '  in  a  case  of  stric- 
ture resulting  from  swallowing  sulphuric  acid.  Senator,^  of 
Berlin,  as  already  indicated  above,  has  used  laminaria  tents 
in  the  treatment  of  malignant  stricture. 

(d)  With  specially  devised  instruments. — Of  all  the  rapid 
methods  of  dilatation,  that  effected  by  an  instrument  inserted 
within  the  stricture  and  then  expanded  is  the  most  forcible 
and  severest.  The  treatment  resembles  that  of  dilatation  of  an 
urethral  stricture  with  a  Holt's  dilator.  Kendal  Franks  ^  has 
recorded  a  case  of  stricture  due  to  injury  from  a  foreign  body, 
where,  by  means  of  Otis's  dilating  urethrotome  without  the 
blade,  he  was  able  to  dilate  the  stricture  to  the  full  size  of  the 
instrument.  Ordinary  bougies  were  passed  for  some  time 
afterwards,  and  the  patient  did  well,  having  only  a  few  slight 
returns  of  recontraction  after  the  lapse  of  eight  years. 

(B)  Through  the  stomach. — The  cases  which  will  fall  to  be 
treated  by  this  method  will  be  those  where  it  is  found  impos- 
sible to  penetrate  the  stricture  from  above.  A  gastrotomy  is 
first  performed,  and  the  orifice  of  the  oesophagus  sought  for 
with  the  forefinger.  A  dilator  is  then  passed  into  the  oesopha- 
gus through  the  guidance  of  the  finger,  and  gently  pressed  up- 
wards through  the  stricture.  When  well  within  the  constricted 
portion  it  is  opened  to  its  full  extent  and  moved  up  and  down 
three  or  four  times  before  withdrawing.  The  stomach  is  then 
closed,  and  lastly  the  abdominal  parietes.  Loreta,^  who  has 
performed  this  operation  three  times  successfully,  states  that 
he  opens  the  dilator  to  the  extent  of  five  centimeters.  In  his 
first  case  the  patient  swallowed  a  good  meal  six  hours  after 
the  operation. 

(3)  Electrolysis. — This  mode  of  treatment  has  developed 
considerably  within  recent  years,  and,  to  judge  by  the   large 

'  Dublin  Joiuiial  of  the  Medical  Sciences,  1879,  3rcl  series,  vol.  Ixviii.  p.  175. 

2  Brit.  Med.  Journ.  1889,  vol.  i.  p.  1417. 

'  Medical  Press  and  Circular,  1882,  vol,  i.  p.  335. 

*  Brit  Med.  Joiirn.  1885,  vol.  i.  p.  374. 

H 


98  THE    CESOPHAGUS 

number  of  cases  now  recorded,  would  appear  to  be  both 
successful  and  free  from  danger.  Fort '  is  reported  as  having 
cured  seven  out  of  nine  cases  in  a  period  of  from  nine  to  thirty 
days.  In  one  case,^  where  the  stricture  was  situated  two  inches 
above  the  cardia,  four  sittings  overcame  the  obstruction. 
Painter^  records  the  case  of  a  woman  who  had  a  band  of  con- 
striction about  sixteen  inches  from  the  incisors.  After  fifteen 
applications — three  being  apphed  weekly — meat  and  bread 
could  be  swallowed  ;  and  after  twenty-five  applications,  lasting 
three  months,  the  patient  could  eat  without  regurgitation  so 
long  as  the  meat  was  cut  up  finely.  Two  cases  are  reported 
by  Kendal  Franks.^  In  one  the  result  is  noted  four  years 
after  the  treatment,  when  no  sign  of  recontraction  could  be 
detected.  The  other,  a  recent  case,  had  so  far  proved  suc- 
cessful. 

The  advantages  of  this  method  of  treatment  would  appear 
to  be  in  the  greater  rapidity  with  which,  as  a  rule,  dilatation 
is  effected  as  compared  with  the  results  of  gradual  distension  by 
bougies;  and  a  less  tendency  to  recontraction.  The  treatment 
is,  however,  usually  combined  with  the  passage  of  bougies. 

This  method  cannot  be  used  when  the  stricture  is  im- 
permeable to  any  instrument.  (For  directions  regarding  the 
practical  application  of  electrolysis  see  Chapter  XVI.) 

(4)  Internal  cesophagotomy. — This  may  be  performed  in  one 
of  two  ways.  Either  (A)  from  above  through  the  mouth,  or 
through  an  opening  in  the  oesophagus  (external  cesopha- 
gotomy) ;  or  (B)  from  below  through  the  stomach. 

(A)  Through  the  mouth. — This  is  the  usual  way,  and  is  per- 
formed only  on  such  strictures  as  are  not  too  tight  to  prevent 
the  introduction  of  the  oesophagotome.  It  is  not  a  method 
of  treatment  in  much  favour  with  English  surgeons,  but 
has  been  practised  more  frequently  in  France,  where  it  was 
originally  introduced.  So  many  disasters  have  resulted  from 
the  cutting  of  strictures  that  the  method  has  not  attair  cd 
to  any  favour.     As  already  indicated,-^  pleurisy,   empyema, 

'  Journal  of  Laryngology  and  Ehinology,  1890,  vol.  iv.  p.  119. 
2  Ibid.  1889,  vol.  iii.  p.  249.  ^  Ibid.  1888,  vol.  ii.  p.  418. 

'  Transactions  of  the  Royal  Academy  of  Medicine  in  Ireland,  1890,  vol.  viii. 
p.  216. 

^  See  above,  Sands,  page  93. 


CTCATRICIAI.    STIUCTUIJE  90 

pneumonia,  and  other  inflammatory  mischief  have  followed 
the  operation.  The  cases  most  suited  for  this  treatment  are 
those  where  the  obstruction  is  due  to  a  localised  fibrous 
band.  The  cesophagotome  is  passed  beyond  the  constric- 
tion, then  expanded  and  withdrawn,  so  dividing  the  stric- 
ture in  its  passage  outwards.  Mackenzie  '  performed  the 
operation  in  one  case,  and  although  the  patient  survived  the 
treatment  three  months,  it  appears  not  improbable  that  death 
was  in  some  way  connected  with  the  pneumonia  and  pleurisy 
which  developed  a  few  hours  after  the  operation.  Eoe,^  using 
Mackenzie's  oesophagotome,  succeeded  in  dividing  without  sub- 
sequent complication  two  cases  of  stricture.  In  one  the  stric- 
ture was  divided  in  three  different  places  ;  in  the  other  in  six. 
In  both,  subsequent  dilatation  was  effected  with  bougies.  The 
paper  by  this  author  may  be  consulted  with  advantage  on  the 
merits  of  the  operation.  He  is  an  advocate  of  it  himself,  and 
quotes  thirteen  cases  besides  his  own  two,  to  show  that  out  of 
a  total  of  fifteen  onlj'  two  deaths  occurred  as  a  direct  result  of 
the  treatment. 

For  the  operation  when  performed  through  an  opening  in 
the  neck,  see  under  External  (Esophagotomy. 

(B)  Through  the  stomach. — The  same  reason  applies  for  open- 
ing the  stomach  to  perform  internal  oesophagotomy  as  in  the 
case  of  the  passage  of  bougies — that  is  to  say,  the  stricture  is 
impassable  from  above  through  the  mouth.  Lange^  reports  the 
case  of  a  girl  4  years  old,  who,  when  2  years  of  age,  swallowed 
a  quantity  of  concentrated  lye.  The  stricture  was  impassable 
from  above,  but  after  gastrostomy  and  several  subsequent 
endeavours  a  small  whalebone  bougie  was  got  through  the 
stricture  from  above  and  pulled  outwards.  A  thread  was  then 
attached  to  the  lower  end,  and  a  series  of  small  blades  forcibly 
drawn  through  the  strictured  portion. 

To  avoid  the  dangers  of  sepsis  instanced  above,  Meyer  has 
proposed  a  method  of  disinfecting  the  oesophagus  by  the  pre- 
liminary combined  performance  of  gastrotomy  and  external 
oesophagotomy.     (See  below.) 

(5)  External  oesophagotomy. — This  operation  implies  either 

'  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  138. 
2  New  York  Medical  Record,  1882,  vol.  xxii.  p.  53G. 
^  Nciu  York  Med.  Journ.  1890,  vol.  li.  p.  131. 

u  2 


100  THE    (ESOPHAGUS 

a  division  of  the  stricture  from  without,  as  in  the  someM'hat 
similar  operation  of  external  urethrotomy,  or  the  temporary- 
opening  of  the  oesophagus  above  the  stricture  for  the  purpose 
of  facilitating  the  passage  of  bougies  or  cesophagotomes.  The 
former  of  these  uses  of  the  operation  has  but  rarely  been 
practised.  Dechambre's  ^  cases,  which  are  quoted  by  some 
authors,  appear  to  have  reference  solely  to  malignant  strictures, 
although  on  one  occasion  at  least  the  operation  was  done  in  the 
belief  that  the  stenosis  was  due  to  syphilis.  In  nearly  every 
case  the  result  was  unsatisfactory.  In  the  case  already  referred 
to  by  Eve,^  where  an  external  oesophagotomy  was  performed 
for  the  extraction  of  a  Symonds's  tube,  the  opportunity  was 
taken  to  divide  the  stricture  also.  The  cesophagus  was  some- 
what forcibly  drawn  up  with  forceps  and  the  cicatricial  stricture 
successfully  divided  with  scissors.  When  seen  two  years  after- 
wards the  patient  had  no  difficulty  in  swallowing,  and  a  No.  18 
bougie  passed  easily.  The  second  use  of  the  operation,  to 
facilitate  the  passage  of  bougies,  has  been  much  more  frequent. 
It  has  been  found  that  when  failure  has  attended  any  en- 
deavour to  introduce  a  bougie  by  way  of  the  mouth,  the  stric- 
ture has  been  overcome  by  introducing  it  through  an  external 
opening  in  the  neck.  The  reason  for  this  is  that  the  course  is 
more  direct,  the  bougie  not  having  to  follow  the  curve  from 
the  mouth.  Another  advantage  also  exists  in  the  possibility 
of  retaining  the  bougie  for  a  longer  time  within  the  stricture, 
such  retention  considerably  facilitating  the  subsequent  and 
easy  passage  of  larger  sizes.  This  mode  of  teatment  finds  a 
strong  advocate  in  Heineke,^  of  Erlangen. 

In  conjunction  w^ith  either  gastrostomy  or  gastrotomy  it 
has  comparatively  recently  been  successfully  adopted  by  Abbe.'* 
(See  also  Tietze,  page  95.)  A  very  fine  conical  gum-elastic 
bougie  was  passed  upwards  through  the  stricture.  To  its  end 
was  attached  a  piece  of  heavy  braided  silk.  After  being  drawn 
through,  it  was  pulled  backwards  and  forwards  in  see-saw 
manner,  and  in  so  doing  the  stricture  was  rapidly  divided. 
Four  months  after  the  operation  the  patient  was  exhibited 
before  the  New  York  Surgical  Society.     Solid  food,  as  well  as 

'  Dictionnaire  cles  Sciences  Medicalcs,  2^  serie,  tome  xiv.  p.  478. 

-  See  paj,'G  95.  •'  Annals  of  Surgery,  1890,  vol.  xii.  p.  360. 

*  Ibid.  l«9a,  vol.  xvii.  p.  4»y. 


CICATRICIAL    STiaCTURE  101 

liquid,  was  swallowed  without  difficulty,  and  the  patient  con- 
tinued to  pass  a  bougie  every  other  day,  to  avoid  the  possibility 
of  recontraction  taking  place.  Still  later,'  when  Abbe  was 
exhibiting  a  second  case  upon  whom  he  had  successfully  per- 
formed the  same  operation,  he  reported  that  his  first  patient 
continued  in  perfect  health.  Kendal  Franks  ^  read  a  papei 
before  the  Koyal  Academy  of  Medicine  in  Ireland  on  this  same 
method  of  treatment,  and  showed  a  patient  upon  whom  he  had 
successfully  performed  the  operation.  He  appends  a  table  of 
twenty  cases  treated  by  gastrotomy  and  retrograde  dilatation, 
to  which  Woolsey  ^  subsequently  added  eight  more.'*  Murray  •' 
showed  at  the  New  York  Surgical  Society  on  October  10,  1894, 
a  child  2  years  old  successfully  treated  by  Abbe's  method.  The 
first  endeavour  failed ;  but  after  a  delay  of  nine  days,  the 
stomach  having  been  stitched  to  the  parietes,  a  fine  bougie 
with  silk  attached  was  passed,  and  the  stricture  sawn  through. 
The  oesophagus  was  not  opened.  At  the  same  meeting  Abbe 
referred  to  his  two  cases  above  quoted,  which  he  stated  to  be 
perfectly  well,  and  '  eating  everything.'  W.  J.  Mayo,''  in  a 
child  3  years  old,  first  performed  gastrostomy  and  one  month 
later  oesophagotomy.  Success  then  followed  Abbe's  string 
method. 

Eklund  ^  has  made  use  of  an  external  oesophagotomy  for 
the  internal  division  of  a  stricture.  He  succeeded  in  intro- 
ducing through  the  opening  Maisonneuve's  urethrotome  and 
divided  the  stricture.  In  order  to  combat  the  septic  after  effects 
of  internal  oesophagotomy  Meyer  ^  has  made  the  following 
suggestion.  Gastrotomy  and  external  oesophagotomy  are  first 
performed.  'Before  starting  the  internal  incision,  irrigate 
the  oesophagus  from  the  fistula  in  the  neck  downward  with 
Thiersch's  solution  or  a  solution  of  permanganate  of  potassium, 
allowing  the  water  to  pass  out  of  the  gastric  opening  and  during 
a  sufficiently  long  time,  to  be  sure  that  this  portion  of  the  canal 

'  Anncds  of  Surgery,  1894,  vol.  xix.  p.  88. 

2  Ihid.  p.  385.  '  Ihid.  1895,  vol.  xxi.  p.  253. 

■»  It  should  be  noted  that  in  seventeen  out  of  these  combined  twenty-eight 
cases  gastrostomy,  and  not  gastrotomy,  was  performed. 
^  Annals  of  Su?-gery,  1894,  vol.  xx.  p.  733. 
*  New  York  Med.  Journ.  1894,  vol.  lix.  p.  433. 
'  Anmcalof  the  Universal  Medical  Sciences,  1890,  vol.  iv.  F— 32. 
•*  Neiv  Tirk  Med.  Joimi.  1892,  vol.  ii.  p.  561. 


102  THE    (ESOPHAGUS 

is  thoronghly  disinfected.  Also  carefully  wash  the  stomach 
from  below.  (This  preparatory  treatment  may  be  repeated 
during  a  number  of  days.)  Push  an  iodoformised  sponge,  or  a 
pad  of  iodoform  gauze  on  a  thread,  into  the  upper  portion  of  the 
oesophagus,  between  the  opening  in  the  neck  and  pharynx,  so 
as  to  guard  against  the  descent  of  the  secretions  of  the  mouth. 
Then  do  internal  oesophagotomy  under  constant  irrigation 
from  the  wound  in  the  neck  downwards.  Continue  the  same 
after  the  operation  is  finished.  The  water  will  run  into  the 
stomach  and  readily  escape  through  the  gastric  fistula.  Finally 
pull  an  iodoformised  sponge,  or  ball  of  iodoform  gauze,  with 
the  help  of  a  bougie  and  thread,  through  the  gastric  opening 
and  the  cardia  into  the  lower  end  of  the  oesophagus.  This 
will  prevent  regurgitation  of  the  contents  of  the  stomach  in  the 
subsequent  direct  feeding  through  the  abdominal  opening.' 

(6)  (Esophagostomy. — This  operation  is  only  possible  when 
the  stricture  is  situated  sufficiently  high  in  the  neck  to  admit 
of  the  opening  into  the  gullet  being  made  below  it.  The  object 
of  the  operation  is  twofold.  In  the  first  place  it  admits  of  the 
patient  being  fed,  and  in  the  second  it  gives  access  to  the 
stricture  above  for  any  treatment  that  may  be  attempted.  It 
is  of  course  limited  to  such  cases  as  are  impassable. 

(7)  Gastrostomy. — This  operation,  essentially  for  the  purpose 
of  feeding  a  patient,  is  usually  adopted  only  in  extreme 
instances.  The  patient  is  generally  much  run  down,  and  the 
stricture  one  which  cannot  be  passed.  Under  these  circum- 
stances the  only  hope  rests  in  opening  the  stomach  and  creating 
an  orifice  for  the  introduction  of  food.  Such  a  measure  as 
this  is  of  course  only  palliative,  but  the  rest  given  to  the 
strictured  part  of  the  gullet  may  admit  subsequently  of  dilata- 
tion being  effected,  as  shown  in  the  case  below.  It  has  been 
shown  above,  however,  that  gastrostomy  may  be  performed 
directly  with  the  object  of  treating  the  stricture  :  that  through 
the  temporary  gastric  orifice,  bougies  or  oesophagotomes  can 
be  introduced.  To  what  extent  life  may  be  prolonged  by  this 
operation,  with  complete  failure  to  dilate  the  stricture,  is  shown 
by  a  case  operated  upon  by  Trendelenburg.^  The  patient  was  a 
boy  who  was  compelled  to  feed  himself  entirely  through  the 

'  MacCormac,  Lancet,  1886,  vol.  i.  p.  192. 


CICATRICIAL    STRICTURE  103 

artificial  opening,  the  food  being  first  masticated  in  the  mouth 
and  then  spat  down  a  tube  into  the  stomach.  The  boy  was 
ahve  and  well  years  afterwards. 

Case  XXXVIII. — Cicatricial  stricture  of  oesophagus  treated  by  gastro- 
stomy, and  subsequent  dilatation  with  bougies. 
'  The  patient,  a  girl,  was  admitted  into  the  Victoria  Hospital  for  Chil- 
dren in  July  1889.  Seven  weeks  previously  she  had  swallowed  some  caustic 
soda.  At  the  time  of  her  admission  she  was  unable  to  swallow  anything 
at  all.  During  August  she  was  fed  entirely  by  nutrient  enemata  and  no 
bougies  were  passed,  so  as  to  give  absolute  rest  to  the  oesophagus.  In 
September,  although  she  had  materially  improved  in  general  condition,  no 
instrument  could  be  passed  through  the  stricture.  On  September  13  the 
CBSophagus  was  opened  in  the  neck  with  the  hope  of  being  able  to  reach 
the  stricture.  The  obstruction,  however,  was  found  to  be  within  the 
thorax.  After  these  wounds  were  closed  with  suturing,  the  first  stage 
of  gastrostomy  was  performed  by  means  of  hare-lip  pins.  Five  days  after, 
the  stomach  was  opened  and  the  child  fed  through  the  gastric  fistula.  On 
January  27, 1890,  a  very  small  whalebone  bougie  was  at  last  passed  through 
the  stricture,  and  after  many  months  of  varying  success  a  No.  14  ceso- 
phageal  bougie  was  eventually  passed  with  ease.  During  1891  this  large 
bougie  was  passed  about  once  a  month,  and  the  plug  removed  from  the 
gastric  opening.  Attempts  were  subsequently  made  to  close  this  opening 
by  passing  the  actual  cautery  along  the  sinus,  and  it  was  now  absolutely 
closed.  She  was  in  perfect  health,  and  caine  to  the  hospital  once  in  six 
weeks  to  have  the  bougie  (No.  14)  passed.  No  contraction  could  be  felt.' 
(Glutton,  '  Trans.  Clin.  Soc.  Lond.'  1892,  vol.  xxv.  p.  253.) 


CHAPTEE  XI 

PARALYSIS    AND    SPASM 


Paralysis. — Cases  of  this  kind  are  rare,  and  are  not  likely 
in  the  first  instance  to  come  under  the  surgeon's  observation. 
The  affection  is  not  infrequently  associated  with  some  other 
neuropathic  symptoms,  and  for  this  reason  the  cases  are 
regarded  as  medical  rather  than  surgical.  It  is  only  when 
the  symptom  of  dysphagia  predominates  and  other  manifes- 
tations are  but  slightly  observable  that  the  surgeon  may  be 
called  upon  to  make  a  differential  diagnosis. 

Etiology. — The  motor  and  sensory  supply  of  the  cesophagus 
being  through  the  vagi,  and  the  latter  taking  their  origin  from 


104  THE    (ESOPHAGUS 

the  medulla,  any  paralysis  of  the  gullet  must  be  effected  in 
one  of  three  ways.  Either  the  origin  or  roots  of  the  nerves 
must  be  involved ;  or  the  trunks  implicated,  somewhere  be- 
tween the  medulla  and  the  canal ;  or  the  muscular  wall  or 
mucous  membrane  so  affected  that  it  will  either  not  receive 
or  not  transmit  impulses. 

Considering  first  such  causes  as  may  affect  the  roots  of 
the  nerves,  any  lesion  in  the  pons  or  medulla  may  cause 
paralysis,  or  even  pressure  communicated  from  some  more 
distant  part.  The  commonest  of  these  lesions  is  that  due  to 
chronic  inflammation  such  as  is  met  with  in  glosso-labio- 
laryngeal  palsy  and  more  rarely  in  the  course  of  lateral 
sclerosis  or  locomotor  ataxia. 

Another  lesion  is  haemorrhage.  Wepf  er,  as  quoted  by  Mon- 
diere,*  has  recorded  a  case  of  death  from  this  cause.  Tumour 
occurring  also  in  these  same  regions  will  give  rise  to  similar 
results.  Montaut,  also  quoted  by  Mondiere,  presented  to  the 
Academie  de  Medecine  a  specimen  of  an  hydatid  cyst  which 
had  developed  at  the  base  of  the  brain  and  by  pressure  on  the 
medulla  caused  paralysis. 

Implication  of  the  vagi  in  their  course  from  the  brain  to 
the  gullet  may  be  reckoned  as  the  rarest  of  the  causes  which 
lead  to  paralysis.  Mondiere's  exhaustive  paper  must  be  again 
referred  to  for  cases  illustrative  of  this  cause.  Thus  Koehler 
saw  a  case  where  the  nerves  were  pressed  upon  by  a  tuber- 
culous mass,  presumably  of  lymphatic  glands ;  and  Wilson  a 
similar  instance,  only  due  to  a  syphilitic  affection  of  the  cer- 
vical vertebrae. 

Affection  of  either  the  muscular  tissue  or  mucous  membrane 
of  the  oesophagus  is  said  to  afford  instances  of  this  condition. 
It  is  difficult,  however,  to  say  whether  it  is  these  tissues  which 
are  at  fault,  or  whether  it  is  the  result  of  certain  specific  in- 
fluences acting  directly  upon  them  or  indirectly,  through  the 
effect  of  these  influences  upon  the  nervous  system.  The 
diseases  here  implied  are  those  which  may  be  termed  general 
or  constitutional ;  such,  for  instance,  as  partial  or  complete 
paralysis  occurring  in  the  course  of  diphtheria,  lead  poisoning, 
Bjl3hilis,  and  some  of  the  acute  fevers. 

'  Archives  GriUrales  de  Medecine,  2"  serie,  tome  iii.  p.  44. 


PAKA  LYSIS  105 

Symptoms. — The  only  symptom  indicative  of  this  affection 
is  difficulty  in  swallowing,  depending  in  its  severity  upon  the 
degree  of  paralysis.  Food  is  taken  and  not  as  a  rule  regurgi- 
tated, but  the  patient  is  conscious  of  its  non-passage  into 
the  stomach  from  a  feeling  of  discomfort  somewhere  in  the 
course  of  the  canal. 

Diagnosis. — Little  difficulty  will  be  found  in  distinguishing 
the  dysphagia  of  paralysis  from  that  due  to  organic  obstruc- 
tion. In  the  first  place  the  history  of  the  case  and  the  presence 
of  other  symptoms  will  of  themselves  frequently  be  sufficient 
to  indicate  the  true  cause  of  the  trouble.  But  should  any 
doubt  still  exist,  it  will  be  readily  cleared  up  by  the  passage 
of  a  bougie,  which  will  be  found  to  pass  without  material 
obstruction.  Auscultation  will  reveal  also  an  absence  of  the 
normal  oesophageal  sound. 

Prognosis. — The  prospect  of  recovery  depends  upon  the 
nature  of  the  cause,  of  which  the  dysphagia  may  be  but  one 
of  the  symptoms.  Where  the  lesion  is  in  the  brain  and  in 
some  part  involving  the  nerves,  little  hope  can  be  entertained 
of  recovery.  Where,  on  the  other  hand,  the  dysphagia  is 
dependent  upon  some  weakness  in  the  muscular  tissue,  or 
connected  with  diphtheria  or  lead  poisoning,  a  good  result  may 
be  looked  for. 

Treatment. — In  cases  where  the  dysphagia  exists  only  as 
a  symptom,  all  curative  treatment  must  be  directed  to  the 
complaint  to  which  it  owes  its  origin.  These  cases,  how- 
ever, being  frequently  the  most  hopeless,  palliative  measures 
must  be  adopted,  and  the  difficulty  in  swallowing  overcome 
by  the  passage  of  a  tube  for  feeding  purposes.  The  patient's 
strength  should  be  kept  up  by  the  administration  of  tonics. 
Iron,  arsenic,  or  strychnine  should  be  given,  and  the  food 
should  be  of  a  nourishing  and  stimulating  character.  In 
order  to  give  some  tone  to  the  muscular  coat,  electricity  may 
be  applied.  The  negative  electrode  should  be  introduced 
within  the  canal,  while  the  positive  is  placed  against  the  skin 
of  the  spine  posteriorly.  According  to  instructions  given  by 
Morell  Mackenzie,  who  states  that  he  has  successfully  adopted 
this  method  in  numerous  cases  annually,  the  treatment  should 
be  carried  out  daily,  if  not  more  frequently,  each  application 
lasting  a  few  seconds,  and  the  time  for  its  use  being  preferably 


lOG  THE     CESOPIIAGUS 

before  meals.     The  treatment  usually  needs  to  be  carried  out 
for  some  weeks. 

Spasm. — In  contrast  with  the  relaxation  of  the  muscular 
coat  of  the  oesophagus,  as  in  the  condition  of  paralysis  just 
described,  we  have  in  spasm  of  the  canal — or  oesophagismus, 
as  it  is  sometimes  called — an  abnormal  contraction  of  this 
coat,  whereby  a  narrowing  of  the  canal  is  produced,  and, 
as  a  consequence,  difficulty  in  deglutition.  More  or  less 
ppasm  always  accompanies  the  impaction  of  a  foreign  body, 
but  such  contraction  is  due  to  local  irritation  produced  by  the 
body  itself,  and  is  therefore  not  included  in  the  present  class 
of  cases. 

Etiology. —  In  a  large  proportion  of  the  cases  the  condition 
is  associated  with  a  highly  nervous  temperament.  This 
appears  in  many  cases  to  be  the  only  explanation.  More 
commonly,  however,  some  localised  exciting  cause  exists,  and 
this,  acting  upon  an  unstable  nervous  system,  produces  the 
condition. 

It  is  difficult,  in  some  of  the  causes  enumerated  below,  to 
trace  the  connection  between  the  exciting  lesion  and  the 
apparently  reflex  spasm.  But  when  it  is  remembered  how 
numerous  are  the  connections  of  the  vagi — the  motor  and 
sensory  nerves  of  the  gullet — with  the  various  tissues  and 
organs  of  the  body,  it  will  at  least  be  gathered  how  many  are 
likely  to  be  the  lesions  which  may  serve  as  incentives  to  an 
attack  of  spasm,  especially  in  a  predisposed  individual. 

Although  the  affection  must  be  distinctly  classified  as  a 
rare  one,  many  cases  have  been  recorded ;  and  as  regards 
the  numerous  causes,  it  is  striking  how  few  cases  there  are 
which  can  be  found  to  so  closely  resemble  each  other,  that 
any  one  particular  lesion  can  be  singled  out  as  specially  fre- 
quent or  common. 

Among  the  various  causes,  then,  which  may  be  mentioned 
as  in  some  way,  either  reflexly,  directly,  or  otherwise,  giving 
rise  to  spasm,  is  profound  emotion,  as  from  fear,  passion,  or 
great  excitement  of  any  kind.  Habershon  ^  mentions  fright 
produced  by  a  thunderstorm.  Hereditary  proclivities  have  been 
traced  in  some  instances.  Imagination  is  a  known  cause,  as 
in  the  belief  of  a  foreign  body  in  the  gullet,  or  as  the  result  of 

'  Diseases  of  the  Abdomen,  2ncl  edit.  p.  19. 


SPASM  107 

being  bitten  by  a  clog,  the  mimicry  being  that  of  hydrophobia. 
To  hydrophobia,  as  is  well  known,  spasm  is  incidental. 

Carcinoiiia  of  the  liver  affords  some  striking  illustrations. 
Mayo  Collier  '  related  a  case,  at  a  meeting  of  the  British  Laryn- 
gological  and  Ehinological  Association,  where  the  patient 
had  suffered  for  three  months  from  difficulty  of  swallowing. 
Death  resulted  from  a  large  cancer  of  the  liver.  No  disease 
existed  in  the  oesophagus  or  elsewhere.  This  author  had  looked 
over  the  record  of  cases  of  cancer  of  the  liver,  and  in  four  of 
them  it  was  noted  that  the  disease  was  associated  with  reflex 
stricture  of  the  oesophagus.  Treves  informed  this  author  also 
that  three  cases  which  had  been  handed  over  to  him  for  opera- 
tion proved  not  to  be  stricture,  but  cases  of  cancer  of  the  liver. 
Affections  of  the  stomach  and  intestines — intestinal  worms  ; 
gout,  especially  as  pointed  out  by  Brinton  ^  when  dyspepsia  is 
a  prominent  symptom  ;  repeated  vomiting ;  pregnancy  and  dis- 
eases of  the  uterus — leucorrhcea,  menorrhagia,  and  dysmenor- 
rhoea ;  various  affections  of  the  ear,  teeth,  tonsils,  nose,  naso- 
pharynx, and  larynx,  as  shown  by  Joal  ^  (this  author  relates 
observations  of  nine  patients  who  were  cured  by  treatment  of 
intranasal  conditions)  ;  chorea  and  epilepsy ;  in  all  these  con- 
ditions it  may  be  met  with.  Lastly,  and  possibly  the  most 
frequent  of  all  causes,  are  hysteria  and  hypochondriasis. 
Instances  of  many  of  these  causes  will  be  found  in  an  exhaus- 
tive paper  on  the  subject  by  Eloy."* 

Eeference  should  be  made  here  to  what  Paget  ^  has  termed 
*  stammering  with  the  oesophagus.'  While  allied  to  spasm, 
Paget  is  inclined  to  consider  it  a  different  affection.  The 
symptoms  resemble  very  closely  those  described  by  the  same 
author  as  characteristic  of '  urinary  stammering.'  *  Sometimes 
swallowing  is  easy  and  unhindered ;  at  others  very  difficult, 
especially  in  company,  or  when  the  trouble  is  particularly  in- 
convenient, or  the  mind  too  much  set  on  it.' 

Symptoms. — The  dysphagia  characteristic  of  spasm  is 
usually  sudden  in  its  onset.     The   patient   may  be  in   the 

'  Journal  of  Laryngology,  1894,  vol.  viii.  p.  94. 

■-=  Lancet,  1866,  vol.  i.  p.  3. 

^  Journal  of  Laryngology  and  Rhinology,  1889,  vol.  iii.  p.  417. 

"•  Gazette  Hebdom.  de  Mdd.  et  de  Chir.  1880,  2'  serie,  tome  xvii.  p.  741. 

*  Clinical  Lecttircs  and  Essays,  1875,  p.  82. 


108  THE    (ESOPHAGUS 

middle  of  a  meal  when  he  suddenly  finds  difficulty  in  swallow- 
ing a  bolus  of  food  or  a  mouthful  of  fluid.  Occasionally  it  is 
at  once  regurgitated,  and  sometimes  so  violently  as  to  be 
ejected  through  the  nostrils.  At  other  times  a  sensation  of 
obstruction  is  felt  which  only  lasts  for  a  short  time,  when  it 
passes  off  and  the  material  is  felt  to  pass  on  into  the  stomach. 
Eegurgitation  is  more  frequent  when  the  spasm  attacks  the 
upper  part  of  the  gullet,  and  in  these  cases  the  food  is  ejected 
immediately  after  being  taken.  The  spasmodic  attacks  vary 
in  frequency  and  severity,  and  may  extend  over  long  periods. 
Although  the  affection  is  mostly  intermittent,  cases  occasion- 
ally reach  a  stage  in  which  there  appears  to  be  no  relaxation 
of  the  spasm. 

Intolerance  of  food  is  sometimes  absolute,  and  an  actual 
distaste  for  it  exists  in  many  cases  associated  with  dyspepsia. 
In  other  cases,  again,  there  is  a  variation  in  the  choice  of 
aliments,  their  temperature,  consistence,  and  nature  being 
matters  of  consideration.  As  a  rule  warm  foods  are  tolerated 
better  than  cold  ;  and  not  infrequently  solids  can  be  taken 
better  than  fluids.  The  sensations  experienced  by  the  patient 
vary.  When  the  spasm  attacks  the  upper  part,  the  patient 
often  imagines  that  a  foreign  body  of  some  kind  is  in  his 
throat.  Spasm  in  this  region  also  is  often  associated  with 
spasmodic  contraction  of  the  muscles  of  the  neck,  and  of  the 
larynx  and  pharynx,  so  that  troubles  in  connection  with  the 
voice  and  respiration  are  complained  of,  amounting  sometimes 
to  feelings  of  strangulation  and  suffocation.  Pain,  when  it 
exists,  varies  in  its  intensity,  duration,  and  seat.  It  is  not 
usually  of  any  diagnostic  value,  but  interscapular  pain  occurs 
when  the  spasm  is  in  the  upper  part  of  the  oesophagus. 
Hiccough  is  sometimes  present.  Emaciation,  when  it  exists, 
indicates  usually  either  that  the  affection  has  lasted  for  a  long 
time,  or  that  it  is  associated  with  gastric  disturbances. 

Along  with  the  dysphagia  there  are  usually  other  sym- 
ptoms of  the  disease  or  functional  disturbance  upon  which 
it  depends.  Thus  in  the  case  of  gout  it  will  probably  be 
'  attended  with  great  acidity  and  loading  of  the  urine  with 
uric  acid  and  urates,  and  is  often  connected  with  tympanitic 
distension  of  the  stomach   and  intestines'   (Brinton).'      In 

'  Lancet,  1866,  vol.  i.  p.  3. 


SPASM  109 

cases  of  hysteria  or  hypochondriasis,  something  in  the 
history  of  the  past  habits  of  the  patients,  or  possibly  in  their 
present  condition,  will  suggest  the  neurotic  origin  of  tlic  com- 
plaint. 

Osgood  '  quotes  some  cases  illustrative  of  what  he  terms 
*  a  peculiar  form  of  oesophagismus.'  In  these  cases  the  attacks 
of  spasm  were  not  limited  to  meal  times ;  and  when  occurring 
at  that  time,  there  was  only  slight  regurgitation.  The  food 
would  be  temporarily  arrested,  and  then  pass  on  into  the 
stomach.  In  some  of  the  cases  the  attacks  occurred  often 
throughout  a  period  of  some  years,  each  attack  lasting  only  a 
few  moments.  The  chief  symptom  was  a  '  localised  distress, 
a  sense  of  clutch,  weight,  or  compression.'  Pain,  often  intense, 
was  felt  at  the  spot  where  the  patient  was  conscious  of  the 
sense  of  constriction.  From  here  it  radiated  to  other  parts, 
and  in  some  cases  was  felt  in  one  or  both  ears.  A  bougie 
passed  with  ease.  No  special  condition  of  the  patient  seemed 
to  suggest  a  cause,  nor  was  there  any  local  lesion  to  which 
a  reflex  influence  could  be  attributed.  The  best  treatment 
was  found  to  be  the  application  of  galvanism  to  the 
epigastrium  and  the  administration  of  effervescing  drinks, 
the  eructations  which  followed  relieving  the  sense  of  con- 
striction. 

Diagnosis. — The  disease  with  which  spasm  of  the  oesopha- 
gus is  most  likely  to  be  mistaken  is  carcinoma,  and  the  fact 
that  spasm  is  sometimes  associated  with  malignant  disease 
renders  the  diagnosis  not  always  devoid  of  difficulty. 
Lacombe's  ^  cases  have  already  been  referred  to.  In  one  of 
these,  carcinoma  of  the  oesophagus  existed  at  one  part  of  the 
gullet,  while  spasmodic  contraction  existed  at  another ;  and  in 
the  second  case,  spasm  was  associated  with  carcinoma  of  the 
stomach.  But  a  certain  amount  of  spasm  often  exists  at  the 
seat  of  the  disease  itself,  and,  as  already  shown, ^  its  sudden 
appearance  in  such  cases  has  often  proved  to  be  the  first 
symptom  of  the  disease.  Excluding,  however,  these  instances, 
there  are  certain  distinctive  features  of  the  affection  which 
should  render  differentiation  comparatively  easy.  The  age, 
sex,  and  general  condition  of  the  patients  are  often  sufficient 

'  Boston  Mfd.  and  Surg.  Juiirn.  1S89,  vol.  cxx.  p.  401. 
-  See  page  G7.  "  See  page  (J-3. 


no  THE    (ESOPHAGUS 

of  themselves  to  enable  a  diagnosis  to  be  made.  Thus  in 
cases  of  spasm  the  patients  are  frequently  young  women  or 
girls,  and  often  in  good  physical  condition.  The  dysphagia 
is  of  sudden  onset  and  generally  intermittent ;  and  when  such 
distinctive  symptoms  exist  as  a  distaste  for  food,  or  a  better 
l^assage  of  solids  than  of  liquids,  or  greater  ease  in  swal- 
lowing warm  than  cold  aliments,  or  immediate  regurgitation 
after  deglutition — the  opposite  of  any  of  which  conditions 
is  the  rule  in  carcinoma — little  doubt  will  exist  as  to  the  true 
nature  of  the  obstruction.  The  diagnosis  will  be  verified 
by  the  passage  of  a  bougie  and  by  auscultation.  The 
passage  of  a  bougie  will  in  some  cases  at  once  settle  the 
question  of  mere  spasm  by  the  ease  with  which  it  passes  into 
the  stomach.  In  other  cases,  however,  the  contact  of  the 
bougie  at  once  increases  the  spasm,  but  with  gentle  and 
persistent  pressure  relaxation  may  follow,  and  the  bougie 
pass  on.  Occasionally,  though  rarely,  the  spasm  is  too 
great  to  be  overcome.  In  such  cases  it  is  wise  to  desist  for  a 
time,  and  try  again  after  the  adoption  of  some  calmative 
therapeutic  measures.  Auscultation  reveals  an  absence  of 
the  normal  oesophageal  sound.  The  arrest  of  the  morsel  will 
be  indicated  by  an  arrest  of  the  sound,  followed  often,  how- 
ever, by  another  sound  of  '  bubbles  of  gas  bursting  in  a  liquid.' 
At  times  an  intermittency  in  the  progress  of  the  bolus  may 
be  made  out. 

Prognosis. — Speaking  generally,  spasm  of  the  oesophagus 
is  a  curable  affection.  It  has,  in  a  few  very  exceptional 
instances,  led  to  a  fatal  result.  Depending  as  it  does  upon 
so  many  causes,  its  duration  and  severity  are  solely  affected 
by  the  disease  to  which  it  owes  its  origin.  Hence,  when  due 
to  a  neurotic  or  functional  disturbance,  a  more  rapid  and  last- 
infT  cure  may  be  expected  than  in  cases  where  there  is  some 
chronic  local  disease  reflexly  producing  the  spasm,  or  some 
more  general  affection,  such  as  gout.  But  in  every  case  the 
relief  of  the  exciting  cause  may  be  suspected  to  be  rapidly 
followed  by  a  subsidence  of  difficulty  in  deglutition. 

Treatment. — As  a  rule,  patients  suffering  from  oesophageal 
spasm  will  need  to  be  treated  for  the  condition  itself,  as  well 
as  for  the  cause  upon  which  it  may  depend.  As  regards  the 
local   treatment,    the    simple  passage    of   a   bougie   may    be 


SPASM  111 

sufficient  to  cure  the  spasm.  In  eases  where  the  mucous 
membrane  appears  intolerant  of  the  presence  of  a  bougie,  the 
parts  may  be  rendered  less  irritable  by  some  topical  applica- 
tion. Mackenzie  found  a  weak  solution  of  nitrate  of  silver 
(five  or  ten  grains  to  the  ounce)  to  answer  best.  The  solution 
is  injected  by  a  tube  or  catheter  to  as  near  the  contracted 
part  as  possible.  In  some  cases  subcutaneous  injections  of 
morphia  have  answered  ;  in  others  the  internal  administra- 
tion of  bromide  of  potassium,  strychnine,  or  belladonna.  In 
one  case  Eloy,'  failing  to  pass  a  bougie,  succeeded  after  giving 
bromide  of  potassium  for  a  few  days.  In  another  case,  the 
same  difficulty  was  overcome  after  subcutaneously  injecting 
morphia  a  few  hours  previously.  The  employment  of  electri- 
city has  succeeded  when  the  passage  of  a  bougie  has  failed. 
As  regards  the  treatment  of  the  various  causes  giving  rise  to 
spasm,  little  need  be  added  here.  Hysteria,  gout,  affection  of 
the  throat,  ear,  &c.  need  each  to  be  dealt  with  according  to 
the  principles  governing  the  ordinary  treatment  of  these 
diseases.  Some  judgment  will  be  required  in  the  proper 
selection  of  nourishment.  Any  food  liable  to  excite  spasm 
should  be  withheld,  and  it  will  generally  be  found  that 
fluids  rather  than  solids  will  answer  best ;  and  warm 
materials  rather  than  cold.  Mackenzie  points  out  thar,  *  in 
nine  cases  out  of  ten  if  the  drink  be  sweetened  it  will  be  borne 
better.' 

Case  XXXIX. — Sj^tasm  of  the  oesojjliagus  due  to  c/oiit. 
A  gentleman  over  60  years  of  age  was  suddenly  seized  with  obstrnc- 
tion  of  the  cesophagus,  which  completely  barred  the  j^assage  of  any  food, 
liquid  or  solid,  into  the  stomach.  The  patient,  who  was  in  excellent 
health,  inadvertently  swallowed  a  piece  of  meat  imperfectly  masticated, 
which  did  not  enter  the  stomach,  but  lodged  in  the  gullet  near  its  cardiac 
extremity.  This  he  recognised  by  the  sense  of  oppression  which  immedi- 
ately ensued  m  the  lower  dorsal  region.  Any  attempt  to  swallow  Huid 
caused  hiccough,  followed  by  the  ejection  of  the  material.  A  probang 
was  introduced,  but  would  not  pass  into  the  stomach.  A  large  bougie  was 
also  tried,  but  any  attempt  to  swallow  fluid  after  still  showed  complete 
obstruction.  No  further  attempts  were  made,  and  the  patient  was 
enjoined  to  keep  at  rest.  Thirty  minims  of  laudanum  Avere  prescribed. 
On  the  following  day  liquid  extract  of  belladonna  was  brushed  freely  over 

'  Gazeftp  Tlehdom.  dp  Med.  et  de  Chir.  1880,  '2''  sevie,  tome  xvii.  p.  808. 


112  THE    CESOPHAGUS 

the  spine  in  the  dorsal  region,  while  ten  minims  of  the  tincture  of  the 
same  drug  were  administered  in  teaspoonful  doses  every  four  hours.  This 
treatment  was  continued  mitil  about  eight  o'clock  in  the  evening,  when,  on 
swallowing  several  small  pieces  of  ice  in  rapid  succession,  it  was  found  that 
they  were  no  longer  rejected,  but  freely  entered  the  stomach.  Shortly 
after  the  patient  was  able  to  regale  himself  with  half  a  pint  of  soup. 
From  this  time  the  dysphagia  entirely  ceased.  The  oesophagus  was  thus 
occluded  for  twenty-four  hours.  The  patient  had  symptoms  of  gout. 
(J.  Moorhead,  '  Lancet,'  1881,  vol.  ii.  p.  164.) 


CHAPTER   XII 


ABNORMALITIES  :     DILATATION.       DIVERTICULA.       CONGENITAL 
ATRESIA.       CONGENITAL    STENOSIS.       TORSION 

Dilatation. — As  distinguished  from  a  pouch  or  diverticulum, 
dilatation  of  the  oesophagus  implies  a  more  or  less  general 
expansion  of  the  canal.  It  may  involve  the  whole  gullet 
between  its  extreme  limits,  or  only  the  lower  segment. 
It  usually  involves  uniformly  the  calibre  of  the  canal,  but 
occasionally,  though  rarely,  there  is  a  greater  bulging  in 
one  direction.  Where  the  dilatation  is  general,  the  widest 
part  is  a.bout  the  middle,  so  that  the  canal  presents  a  some- 
what fusiform  outline.  In  cases  following  upon  obstruction 
at  the  cardia,  the  widest  part  is  near  that  region. 

Etiology. — Numerous  causes  have  been  suggested  as  giving 
rise  to  this  rare  condition.  That  it  occasionally  ensues  as  the 
result  of  some  form  of  obstruction  is  certain.  In  cases  both 
of  carcinoma  and  cicatricial  stricture  instances  have  been 
recorded,  and  in  one  case  at  least  it  seems  to  have  resulted 
from  external  pressure.  In  this  particular  instance,  reported 
by  Handford,^  the  patient  had  an  enormously  dilated  aorta, 
which  caused  obstruction  by  pressing  the  oesophagus  against 
the  unyielding  central  tendon  of  the  diaphragm.  Among 
other  obstructive  influences  Einhorn  ^  has  suggested  two, 
spasm  of  the  cardia,  and  defective  reflex  relaxation  of  the 
same  orifice.     The  former  of  these   cases    appears  to  have 

'  Trans.  Path.  Soc.  Lond.  1888,  vol.  xxxix.  p.  103. 
-  New  York  Medical  Record,  1888.  vol.  xxxiv.  p.  751. 


DlI.A'I'A'l'ION  113 

existed  in  a  case  reported  by  Leichtenstern.'  A  girl,  19 
years  of  age,  had  had  vomiting  for  seven  years,  attributed  to 
hysteria.  At  the  post  mortem  an  enormous  dilatation  of  the 
thoracic  portion  of  the  oesophagus  was  found.  The  cardiac 
orifice  was  spasmodically  contracted,  and  that  this  was  the 
primary  cause  was  strongly  insisted  upon  by  the  author. 
Other  cases  seem  to  depend  more  directly  on  the  condition  of 
the  wall  of  the  gullet  itself;  thus  catarrhal  affection  of  the 
mucous  membrane  appears  to  have  been  a  likely  incentive 
in  more  than  one  instance,  as  for  example  Bristowe's,^ 
Luschka's,^  and  Hannay's  ^  cases.  The  explanation  given  by 
the  last  author  is,  that  the  inflammation  extends  into  the 
muscle  tissue  so  as  to  damage  its  structure  and  impair  its 
function,  the  result  being  that  food  accumulates  and  distension 
takes  place.  Among  other  causes,  paralysis  and  general 
muscular  atrophy  have  been  given.  A  case  recorded  by 
Klebs  ■''  is  said  to  illustrate  the  latter.  That  disease  of  the 
vagi  should  give  rise  to  dilatation  has  been  theoretically 
suggested  by  Einhorn,  who  based  his  opinion  upon  the  physio- 
logical experiment  that  division  of  the  vagus  causes  food  to 
lodge  in  the  lower  part  of  the  gullet.  In  four  recorded  instances 
by  Hannay,  Purton,*'  Davy,^  and  Einhorn,  the  patient's  first 
symptoms  of  dysphagia  dated  back  to  an  accident.  In  the 
cases  of  the  first  two  authors  it  was  a  severe  blow  on  the 
sternum,  in  Davy's  after  a  violent  strain,  and  in  Einhorn's  after 
a  fall.  What  connection  exists  between  these  alleged  causes 
and  the  conditions  under  consideration  it  is  difficult  to  say. 
That  some  cases  are  congenital  is  confirmed  by  the  observation 
of  Zenker,^  who  found  on  examining  the  body  of  a  seven-months 
child,  which  died  when  7  days  old,  a  spherical  dilatation 
of  the  lower  end  of  the  oesophagus.  The  case  recorded  by 
Wilks  ^  was  believed  by  that  author  to  have  such  an  origin,  or 

'  Solis-Cohen,  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  iv. 
F     28. 

2  Brit.  Med.  Journ.  1887,  vol.  ii.  p.  885. 

'   Virchow's  Archiv,  Bd.  xlii.  p.  473. 

^  Edinburgh  Medical  and  Surgical  Journal,  July  1833,  p.  68. 

*  Ziemssen's  Gyclopcedia  of  Medicine,  vol.  viii.  p.  51. 

"  London  Medical  and  Physical  Joutnal,  vol.  xlvi.  p.  540. 
'  Medical  Press  and  Circular,  1875,  vol.  i.  p.  382. 

*  Ziemssen's  Cyclopcedia,  vol.  viii.  p.  51. 

"  -Trans.  Path.  Soc.  Land.  18GG,  vol.  xvii.  p.  138. 

I 


114  THE   CESOPHAGUS 

possibly  more  correctly  the  stricture  which  existed  below  the 
dilatation.  The  enlargement  of  the  canal  at  such  an  early 
period  of  life  has  suggested  the  homology  of  the  first  stomach 
of  a  ruminant.  Knott  ^  points  out  that  a  distinguishing 
pathological  feature  between  congenital  and  acquired  dilata- 
tions is  that  in  the  former  '  the  muscular  coats  of  the  oeso- 
phagus are  found  to  be  hypertrophied,'  while  in  the  latter 
'  the  opposite  condition  of  atrophy  and  attenuation  is  some- 
times met  with.'  Eolleston  ^  reported  to  the  Pathological 
Society  of  London  the  case  of  a  boy  aged  8  years  who  died 
after  six  weeks'  vomiting.  As  pointing  to  a  nervous  origin,  a 
brother  of  the  boy  had  died  of  vomiting  after  scarlet  fever, 
and  an  uncle  was  also  said  to  have  died  of  vomiting.  There 
was  hypertrophy  of  the  muscle  coat,  but  no  annular  hyper- 
trophy at  the  cardiac  orifice. 

Symptoms. — The  dysphagia  and  regurgitation,  which  are 
the  prominent  symptoms  of  dilatation,  are  often  of  prolonged 
duration,  in  some  cases  dating  back  to  childhood.  Although  the 
disease  may  be  congenital,  the  symptoms  do  not  usually  appear 
till  the  patient  is  some  years  of  age.  The  difficulty  in  swallow- 
ing, at  first  only  slight,  gradually  increases,  and  is  accompanied 
by  pain  which  varies  in  degree  and  kind.  It  is  usually  located 
at  some  particular  spot,  where  a  sense  of  obstruction  also 
exists.  Eelief  is  often  obtained  by  the  adoption  of  some 
special  attitude ;  thus  Einhorn's  patient  would  walk  up  and 
down,  making  deep  inspiratory  and  expiratory  efforts,  at  the 
same  time  pressing  forcibly  with  his  hand  :  by  such  means 
he  was  enabled  to  get  the  food  into  his  stomach,  and  so  relieve 
himself  of  the  pain  and  inconvenience.  Davy's  patient  '  was 
obliged  to  take  his  meals  in  a  semi-recumbent  posture,  with 
his  right  arm  over  the  back  of  the  chair.'  Gradenwitz  ^ 
recorded  a  case  where  the  man  had  to  stretch  himself,  when 
the  food  was  heard  to  enter  his  stomach  with  a  loud  gurgling 
sound.  In  other  cases  relief  can  only  be  obtained  by  vomiting, 
the  feeling  of  distension  becoming  so  intolerable  that,  rather 
than  wait  and  strive  to  get  the  food  down,  the  patient  ejects 
the  contents  of  the  distended  gullet  through  the  mouth.     An 

'  Pathology  of  the  QiJsophagus,  p.  19. 
2  Brit.  Med.  Journ.  1895,  vol.  ii.  p.  1425. 
=•  Schmidt's  Jahrbiich,  1859,  vol.  ci.  p.  298. 


DILATATION  115 

example  of  such  a  case  is  recorded  by  Viti.'  The  patient  was 
in  the  habit  of  making  himself  vomit,  to  relieve  the  feeling 
of  weight  which  he  suffered  from  after  meals.  He  died  from 
the  ruptm'e  of  a  varicose  vein  in  the  oesophagus,  and  at  the 
post  mortem  a  sacciform  dilatation  was  found  just  above  the 
cardiac  orifice. 

The  length  of  time  after  taking  food  before  it  is  regurgitated 
varies.  In  some  cases  it  is  returned  almost  immediately, 
while  in  other,  hours,  and  even  days  (Purton)  may  elapse. 
In  any  case,  the  food  so  ejected  is  found  to  be  free  of 
pepsin  and  hydrochloric  acid,  thus  indicating  that  it  does 
not  come  from  the  stomach.  The  longer  the  food  remains 
lodged  the  more  likely  is  it  to  decompose,  with  the  result 
that  the  breath  may  become  very  offensive.  Where  the 
distension  is  considerable,  the  heart's  action  maybe  mechani- 
cally impeded  and  symptoms  of  faintness  ensue.  The  degree 
of  emaciation  will  depend  upon  the  quantity  of  nourishment 
which  finds  its  way  into  the  stomach.  Mucus  and  saliva 
collects  sometimes  to  a  considerable  extent  and  is  hawked  up. 
Troublesome  coughing  is  also  occasionally  present,  and  serves 
to  produce  attacks  of  vomiting. 

Diagnosis. — It  will  be  readily  understood  how  apt  such  cases 
are  to  be  set  down  as  due  to  stricture.  The  length  of  time 
since  the  onset  of  the  dysphagia,  the  age  of  the  patient,  and  the 
general  history  of  the  case  will  largely  assist  towards  a  correct 
dift'erentiation.  But  the  most  confirmatory  evidence  of  dila- 
tation will  be  found  in  the  ease  with  which,  in  the  majority  of 
cases,  a  large-sized  bougie  may  be  made  to  pass  into  the 
stomach.  That  success,  however,  should  follow  such  attempts, 
the  passage  of  the  bougie  must  only  be  tried  when  the  gullet 
is  empty  ;  that  is  usually  after  the  patient  has  vomited.  As 
indicated  by  Morell  Mackenzie,^  even  under  these  conditions 
difficulty  is  sometimes  encountered  owing  to  the  twisting  or 
doubling  of  the  bougie  upon  itself. 

Prognosis. — "While  it  may  be  said  to  be  impossible  to  cure 
this  disease,  much  may  be  done  to  prolong  life.  "When  death 
is  directly  due  to  the  dilatation,  it  is  usually  the  result  of 
inanition  ;    hence  it  may  be  expected  that  the   sooner   the 

'  Brit.  Med.  Journ.  Epitome,  1890,  vol.  ii.  p.  65. 
*  Diseases  of  the  Tliroat  and  Nose,  vol.  ii.  p.  117. 

1  2 


116  THE   (ESOPHAGUS 

ejection  of  the  food,  and  the  larger  the  amount  of  such  ejec- 
tion, the  shorter  is  likely  to  be  the  patient's  life.  That  life 
may  be  prolonged  for  several  years  is  abundantly  shown  by 
some  of  the  cases  already  quoted.  Thus  in  Davy's  case  the 
symptoms  were  observed  for  ten  years  ;  in  Purton's  for  twenty  ; 
in  Hannay's  for  thirty  ;  in  Gradenwitz's  for  forty-three  ;  and  in 
Wilks'  case,  which  was  supposed  to  be  congenital,  the  patient 
lived  till  he  was  74  years  old. 

Treatment. — Much  may  be  done  by  careful  attention  to 
diet,  and,  in  some  cases,  by  a  properly  regulated  use  of  a 
feeding  tube.  The  food  taken  should  be  in  small  quantities, 
in  large  part  fluid,  and  taken  at  frequent  intervals.  The 
patient's  feelings,  however,  will  often  prove  the  best  guide  both 
as  to  the  quantity  and  quality  of  nourishment  required.  Every 
endeavour  should  be  made  to  prevent  an  accumulation  in  the 
gullet.  The  use  of  a  feeding  tube,  where  considered  necessary, 
not  only  enables  a  proper  amount  of  nourishment  to  reach  the 
stomach,  but  gives  rest  to  the  oesophagus,  permitting  the  latter 
to  recover  a  certain  amount  of  its  contractile  power.  Mermod, 
quoted  by  Solis-Cohen,  records  a  case  of  rapid  improvement 
in  general  health  and  in  the  local  distressing  symptoms  by 
the  use  of  the  feeding  tube.  In  cases  where  the  dilatation  is 
secondary  to  stricture,  the  latter  will  need  to  be  treated  in 
one  or  other  of  the  ways  already  indicated  for  that  condition. 

Case  XL. —  Dilatation  of  the  oesophagus  stijpervening  upon  a  fall. 
About  fourteen  days  after  a  fall  the  patient  began  to  have  a  feeling  of 
fulness  afier  eating,  and  a  sense  of  pressure  about  the  epigastric  region. 
Two  or  three  weeks  later  he  experienced  some  difficulty  in  taking  food,  and 
tried  to  assist  its  passage  by  drinking  warm  water  several  times  during  his 
meal;  only  by  so  doing  was  he  enabled  to  enjoy  a  whole  meal.  His 
dysphagia  increased,  and  in  order  to  get  down  his  food  he  used  to  leave 
the  table  in  the  middle  of  a  meal,  walk  up  and  down  the  room, 
taking  deep  inspirations  and  expirations.  He  would  press  with  his  hands 
upon  the  front  of  the  lower  part  of  the  thorax,  after  taking  a  deep  inspira- 
tion and  closing  his  glottis.  This  method  of  manipulation  brought  him 
relief,  allowing  him  to  eat  again.  "When  in  the  recumbent  position,  fluid 
at  times  came  up  into  his  throat  and  mouth,  and  from  time  to  time  it 
happened  that  he  awoke  with  his  mouth  full  of  fluid.  He  rapidly 
emaciated,  and  became  greatly  distressed  and  miserable.  No  organic 
mischief  was  discovered  anywhere.  He  had  a  feeling  of  pressure  round 
his  chest,  and  he  was  much  troubled  with  cough.  On  passing  the  tube  of 
a  stomach  pump,  no  resistance  was  enci  untered.      The  treatment  con- 


DIVERTICULA  117 

sisted  in  allowing  the  patient  to  take  only  fluid  or  semi-fluid  nourish- 
ment :  in  washing  out  his  oesophagus  every  night  before  going  to  bed  ;  and 
in  passing  a  tube  into  his  stomach  once  a  day.  Both  these  latter  measures 
he  managed  to  carry  out  himself.  He  gradually  improved.  (Eiuhorn, 
'  New  York  Medical  Eecord,'  1888,  vol.  xxxiv.  p.  751.) 


CHAPTER   XIII 

ABNORMALITIES    {continued).      DIVERTICULA 

Although  rare,  this  condition  is  much  more  frequently  met 
with  than  the  last ;  and  from  the  fact  that  it  has  now  been 
successfully  treated  by  operation,  it  may  be  considered  less 
serious.  Numerous  cases  are  to  be  found  recorded,  and  it 
is  more  than  probable  many  others  escape  observation. 
Butlin,^  in  a  paper  read  before  the  Royal  Medico- Chirurgical 
Society  of  London,  gives  illustrations  of  all  the  specimens 
met  with  in  the  London  collections.  Two  exist  in  the  Royal 
College  of  Surgeons,  and  three  in  the  museums  of  the  London 
hospitals.  The  condition  does  not  always  give  rise  to  sym- 
ptoms, and  occasionally  diverticula  are  accidentally  met  with 
in  the  course  of  a  post  mortem. 

Etiology. — The  origin  of  these  pouches  is  usually  ascribed 
to  one  of  four  causes  :  either  ihey  are  (1)  congenital,  or  they 
are  dependent  upon  a  (2)  strictured  condition  of  the  canal 
below,  or  they  result  from  (3)  pressure  within  or  (4)  traction 
from  without. 

(1)  Congenital. — In  a  paper  read  by  Francis^  before  the 
Cambridge  Medical  Society,  the  author  suggested  three  theories 
for  their  occurrence  :  firstly,  that  they  might  be  analogous  to 
the  diverticula  which  were  found  in  some  of  the  Sauropsida 
and  in  ruminant  animals — forming  the  first  two  compartments 
of  the  stomach ;  secondly,  that  they  were  foetal  varieties  ana- 
logous to  the  oesophageal  diverticulum  from  v/hich  the  larynx, 
trachea,  and  lungs  are  formed  ;  and  thirdly,  that  they  resulted 
from  a  failure  in  the  internal  closure  of  a  branchial  cleft. 

(2)  Stricture. — In  cases  resulting  from  this  cause,   it  is 

'  Trans,  1893,  vol.  Ixxvi.  p.  269. 
^  Lancet,  1887,  vol.  ii.  p.  1271. 


118  THE    CESOPHAGUS 

supposed  that  some  spot  above  the  obstruction,  weakened 
through  mflammation  and  ulceration,  gradually  yields,  and  on 
account  of  the  repeated  pressure  to  which  it  is  subjected  in 
eyery  act  of  deglutition,  the  wall  becomes  forced  out  into  a 
pouch.  The  condition  is  likened  to  similar  pouches  found  in 
the  bladder  and  rectum,  where  a  stricture  prevents  the  normal 
escape  of  the  contents  of  the  viscus. 

(3)  Pressure. — In  this  class  it  is  assumed  that  there 
already  exists  naturally  some  predisposed  weakened  spot  in 
the  walls  of  the  gullet,  the  continual  subjection  of  which  to 
the  normal  pressure  exercised  in  deglutition  leads  to  the 
formation  of  a  pouch.  Not  therefore  that  there  is  undue 
pressure  within,  but  that  there  exists  abnormal  weakness  in 
the  walls.  One  place  which  appears  thus  to  be  specially 
disposed  is  the  junction  of  the  pharynx  with  the  oesophagus 
posteriorly.  Here  the  inferior  constrictor  above  merges  with 
the  circular  muscle  fibres  of  the  oesophagus  below,  both  being 
placed  transversely ;  and  since  also  this  is  the  narrowest 
j)art  of  the  canal,  where  anteriorly  is  situated  the  unresisting 
cricoid  cartilage,  greater  pressure  in  deglutition  is  brought 
to  play  here  than  in  any  other  part  of  the  canal.  Strangely 
nature  seems  to  have  failed  in  not  compensating  for  this  weak- 
ness, although  it  must  be  confessed  that,  considering  the 
rarity  of  the  disease,  it  may  well  be  questioned  whether  we 
are  wholly  correct  in  blaming  nature  and  not  some  other  un- 
natural cause.  It  may  be  well  to  remark  here  that  these 
particular  diverticula  are  sometimes  described  as  pharyngeal. 
Occurring  as  they  do  at  the  junction  of  pharynx  and  oeso- 
phagus, they  have  perhaps  as  much  right  to  be  associated 
with  the  one  as  the  other  ;  but  considering,  on  the  other  hand, 
that  the  symptoms  are  almost  always  oesophageal  in  character, 
it  would  appear  better  to  retain  them  in  this  connection. 

Another  cause  of  abnormal  weakness  has  been  indicated  by 
Fere.^  He  found  that  on  making  a  microscopical  examination 
of  the  oesophagus  of  a  new-born  child,  perpendicular  to  the  long 
axis  of  the  canal,  there  was  a  small  region  about  one  centimeter 
below  the  upper  extremity  of  the  tube,  and  in  the  median  line 
anteriorly,  where  the  muscular  coat  was  completely  absent. 

'  Le  Progris  Medical,  1879,  No.  7,  p.  227. 


PLATE    VI 


Fig.  15.— DiVLRTlCULUM  OF  THE  CEsOPHAGUS.— The  posterior  wall  of  the  pharynx 
and  the  diverticulum  is  laid  open.  Two  directors  mark  the  continuation  of 
the  .yullet.     (Hiii/t^r  tv/  Museum,  Univcnitv  of  GUisgow.) 


DIVERTICULA  119 

Struthers,  as  quoted  by  Francis,  points  out  an  area  of  weak- 
ness a  little  below  the  bifurcation  of  the  trachea,  due  to  the 
absence  of  any  material  external  support  to  the  gullet  in  this 
situation. 

(4)  Traction. — By  this  method  the  wall  of  the  oesophagus 
is  acted  upon  by  some  external  inflammatory  influence,  which 
in  the  process  of  healing  and  contraction  leads  to  the  forma- 
tion of  a  funnel-shaped-like  process.  These  diverticula  are 
found  most  commonly  opposite  or  near  the  bifurcation  of  the 
trachea.  The  reason  for  this  lies  in  the  greater  frequency 
with  which  inflammatory  processes  take  place  in  connection 
with  the  lymphatic  glands  situated  in  this  region.  A  specimen 
was  shown  by  Latham  ^  to  the  Cambridge  Medical  Society  in 
illustration  of  such  a  process.  The  patient  died  of  phthisis.  A 
large  abscess  cavity  at  the  bifurcation  of  the  trachea  communi- 
cated with  the  oesophagus  and  simulated  a  traction  diverticulum. 

The  pouches  or,  better,  infundibuliform  processes  are 
usually  directed  transversely  outwards,  or  obliquely  upwards, 
so  that  their  size  is  not  materially  affected  by  the  lodgment 
of  any  quantity  of  food.  There  is  risk,  however,  associated  with 
small  fragments  becoming  impacted.  In  such  cases  ulcera- 
tion may  be  set  up,  leading  to  the  formation  of  a  septic  abscess  ; 
and  this  latter,  finding  its  way  into  some  neighbouring 
structure  or  organ,  may  cause  a  fatal  result.  In  a  case  re- 
ported by  Leichtenstern,^  perforation  took  place  into  the  lung, 
and  death  ensued  from  pulmonary  gangrene.  Besides  the 
pathological  process  involved  in  the  formation  of  these  diverti- 
cula, Francis,  in  his  paper,  adds  a  physiological  one,  in  the 
action  of  the  musculus  pleuro-broncho  oesophageus  of  Hyrtl 
and  Cunningham. 

Diverticula  occasionally  arise  from  the  inpaction  of  foreign 
bodies.  In  one  sense  these  might  be  deemed  pressure  diverticula, 
but  they  differ  in  this  respect,  that  they  are  essentially  due  to 
pressure,  and  not  to  any  abnormal  weakness  in  the  walls  of 
the  gullet.  In  most  of  these  cases  the  pouch  simply  forms  a 
sac  for  the  encystment  of  the  foreign  body,  and  must  be 
considered  as  a  means  of  cure ;  in  other  cases,  however,  it  is 
possible,  either  from  a  gradual  increase  in  the  size  of  the  sac 

'  Lancet,  1887,  vol.  ii.  p.  1271. 

-  Journal  of  Laryngology  and  Rlmiology,  1891,  vol.  v.  p.  240. 


120  THE    (ESOPHAGUS 

wl^ile  the  body  is  retained,  or  a  similar  increase  after  its  ejec- 
tion, for  a  true  diverticulum  to  be  produced.  In  a  case  recorded 
by  Hoffman,^  a  diverticulum  resulted  from  the  swallowing  of 
a  j)iece  of  broken  china.  The  man,  who  had  tried  to  commit 
suicide,  died  on  the  following  day,  and  a  hole  was  found 
in  the  wall  of  the  upj)ermost  region  of  the  oesophagus  lined 
with  mucous  membrane.  The  author  regarded  this  as  an 
instance  of  an  acute  diverticulum. 

Pathology. — In  structure  diverticula  vary.  In  some  cases 
they  possess  a  wall  of  mucous  membrane,  submucous  tissue, 
and  muscle ;  while  in  others  there  is  an  absence  of  any 
muscle  tissue,  the  sac  consisting  of  a  dense  substratum  of 
fibrous  tissue  lined  with  mucous  membrane.  The  existence 
of  muscle,  except  around  the  orifice  of  the  sac,  is  denied 
by  Zenker,^  who  failed  in  a  number  of  careful  observations 
to  detect  its  prt-sence.  If,  for  the  present,  traction  diver- 
ticula be  excluded,  the  other  forms  may  be  said  to  be  either 
true  hernial  protrusions  of  the  lining  membrane,  or  possibly 
foetal  varieties  of  the  same  nature  as  the  normal  diverticulum 
of  the  oesophagus,  from  which  the  lungs  are  developed.  In 
size  and  shape  they  exhibit  considerable  varieties.  In  most 
instances  the  size  depends  upon  the  time  the  pouch  has  been 
in  existence.  Small  at  its  origin,  it  enlarges  from  repeated 
fillings  and  continuous  pressure.  In  some  cases  the  opening 
into  the  pouch  is  much  narrower  than  its  body  or  fundus, 
giving  the  sac  a  pedunculated  or  pear-shaped  appearance  ;  in 
others  the  reverse  conditions  are  found,  and  the  orifice  of  the  sac 
not  only  larger  than  the  sac  itself,  but  in  excess  of  the  calibre  of 
the  oesophagus  in  its  continuity  below.     (See  PL  VI,  fig.  13.) 

As  .may  be  gathered  from  what  has  preceded,  the  most 
frequent  position  for  diverticula  is  opposite  the  cricoid 
cartilage.  As  the  sac  increases  in  length  it  passes  downwards 
between  the  gullet  and  the  spinal  column  ;  and,  owing  to  the 
resistant  action  of  the  latter,  any  increase  in  the  bulk  of  the 
pouch  causes  pressure  upon  the  oesophagus  in  front.  This 
becomes  greater  the  lower  the  tumour  descends.  By  reason  of 
the  counter  resistant  action  of  the  sternum,  the  oesophagus 


'  Journal  of  Laryngology  and  Ehinology,  1889,  vol.  iii.  p.  293. 
^  CyclopcBdia  of  Medicine,  vol.  viii.  p.  58. 


DIVEirnCULA  121 

gets    squeezed  by    the  distended   pouch  between    the  spine 
behind  and  the  manubrium  in  front. 

As  indicated  in  describing  the  etiology  of  diverticula,  they 
are  occasionally  met  with  in  other  situations  than  that  just  de- 
scribed. Thus  Reichmann  '  records  three  cases  and  Mintz  ^  one 
where  the  diverticulum  was  found  at  the  lower  part  of  the  canal. 
Moore  ^  reports  a  case  where  the  pouch,  no  larger  than  a  pea, 
was  found  anteriorly  at  a  point  a  little  below  the  end  of  the 
trachea.  Traction  diverticula,  as  stated  above,  are  most  fre- 
quently found  somewhere  in  the  locality  of  the  bifurcation  of 
the  trachea. 

Symptoms. — As  a  rule  it  is  not  until  the  diverticulum  has 
reached  a  sufficient  size  through  the  increasing  accumulation 
of  food,  that  the  patient  begins  to  complain  of  some  sense  of 
obstruction  or  oppression,  localised  usually  at  a  spot  on  the 
neck  or  chest  opposite  the  seat  of  impediment.     Occasionally, 
however,  obstruction  takes  place  at  the  orifice  of  the  pouch, 
independently  of  any  distension  of  the  sac  itself.     Intimately 
associated  with   the  pain   and    feeling  of  oppression    is  the 
immediate    relief  experienced    when   the  patient  ejects    the 
contents    of  the    sac.     This    occurs  in  some  cases  involun- 
tarily, but  is  more  frequently  effected  by  the  patient  himself. 
When  the  diverticulum  exists  in  the  neck,  it  can  sometimes  be 
felt  as  a  tumour  situated  deeply  beneath  the  gullet,  and  is 
observed  to   project  laterally,  or  produce  an  appearance   of 
fulness  when  food  is  taken.     On  pressing  the  swelling,  as  can 
be  accomplished  by  the  patient  himself,  the  contents  of  the 
sac  may  be  heard  to  gurgle  into  the  mouth.     The  feeling  of 
obstruction  is  occasionally  felt  to  begin  above  and  descend. 
This  occurred  in  a  case  reported  by  Weinlechner,''   who  ex- 
plained it  by   assuming  that  the  difficulty  first  felt  was    at 
the  orifice  of  the  pouch,  but   as   the  latter  filled,  it  caused 
greater  pressure  lower  down.     The  reverse  sensation  has  also 
been   experienced — that   is,    the   feeling   of  obstruction   has 
appeared  to  ascend.     Thus  in  one  of  Eeichmann's  three  cases, 
when  the  feeling  of  difficulty  in  swallowing  had  risen  to  a  cer- 

'  Journal  of  Laryngology  and  Rhinology,  1893,  vol.  vii.  p.  233. 

=  Ibid.  p.  232. 

3  Trajis.  Path.  Soc.  Lond.  1882,  vol.  xxxiii.  p.  191. 

■*  Wiener  vied.  Wochensclirift,  1880,  p.  36. 


V22  THE   (ESOPHAGUS 

tain  point,  the  patient  noticed  that  food  passed  into  the  stomach. 
In  this  instance  the  empty  diverticulum  did  not  appear  to  cause 
trouble ;  but  as  the  sac  filled  so  the  sense  of  pressure  on  the 
oesophagus,  or  rather  the  obstruction  caused  by  the  pressure, 
was  felt  by  the  patient  to  rise  upwards,  until  the  sac  being 
finally  filled,  the  excess  passed  downwards  into  the  stomach. 
In  other  such  cases  the  complete  filling  of  the  diverticulum 
implies  total  obstruction.  In  a  case  reported  by  Chavasse  ^ 
such  was  the  result,  and  gastrostomy  had  to  be  performed  to 
prevent  death  from  starvation.  The  length  of  time  during 
which  food  may  remain  in  a  diverticulum  varies.  In  some 
instances  it  amounts  to  days,  and  under  such  circumstances 
the  contents  are  liable  to  decompose  and  the  breath  become 
foetid.  Food  regurgitated  will  be  found  to  be  free  from  any 
acid  reaction  and  show  no  signs  of  having  undergone  diges- 
tion, thus  proving  its  return  from  the  oesophagus  and  not  the 
stomach.  A  large  diverticulum,  occurring  either  in  the  neck  or 
in  the  thorax,  may  produce  serious  symptoms  from  pressure  on 
blood  vessels  and  nerves  ;  and  even  the  heart's  action  may  be 
impeded  when  the  swelling  projects  forwards  to  any  material 
degree  in  the  posterior  mediastinum. 

Diagnosis. — But  little  difticulty  is  encountered  in  diagnos- 
ing many  of  those  diverticula  which  occur  in  the  neck.  The 
existence  of  a  tumour  which  is  found  only  to  form  during 
deglutition,  and  to  be  capable  of  being  emptied  by  pressure, 
may  be  said  to  be  pathognomonic.  Where,  however,  the 
diverticulum  is  situated  in  the  thorax,  some  difficulty  will  arise 
in  distinguishing  the  affection  from  stricture  and  dilatation. 

Excluding  such  aids  to  diagnosis  as  may  be  elicited  from 
the  history  of  the  case,  its  onset  and  progress,  the  most  con- 
firmatory evidence  will  be  obtained  from  the  use  of  a  bougie. 
In  any  endeavour  to  pass  an  instrument  when  the  diver- 
ticulum is  filled  with  food,  it  will  generally  be  found  that  the 
point  of  the  bougie  or  tube  will  make  its  way  into  the  dis- 
tended orifice  ;  while  if  an  attempt  be  made  when  the  pouch 
is  empty,  there  is  a  chance  of  it  escaping  the  opening  and 
passing  with  ease  into  the  stomach.  Independently,  however,  of 
such  a  condition  the  bougie  will,  in  the  same  case,  at  one  time 

'  Srans.  Path.  Soc.  Lond.  1891,  vol.  xlii.  p.  82. 


DIVERTICULA  123 

pass,  while  at  another  it  will  not.  Weinlechner  '  believes  this 
inconstancy  to  be  due  to  a  valvelike  condition  of  the  mucous 
membrane  at  the  orifice  of  the  diverticulum.  Such  a  sequence 
of  events  will  at  once  exclude  stricture,  but  may  still  leave 
some  doubt  as  to  the  alternative  existence  of  dilatation.  A 
few  repeated  passages  of  the  instrument  will,  however,  soon 
eliminate  the  latter,  and  the  fact  that  a  cavity  is  detected 
capable  of  being  washed  out  will  further  aid  towards  a  correct 
diagnosis. 

Prognosis.^ — Unless  some  relief  can  be  given,  the  prognosis 
is  bad.  According  to  von  Bergmann,^  thirteen  out  of  twenty- 
one  cases,  or  nearly  75  per  cent.,  are  fatal.  Death  usually 
occurs  from  inanition,  and  the  length  of  life  will  naturally 
depend  upon  the  amount  of  nourishment  which  can  find  its 
way  into  the  stomach.  In  Weinlechner's  '  case  the  man  was 
64  years  old,  and  he  had  had  symptoms  for  thirteen  years  ;  in 
Chavasse's  case,  symptoms  had  existed  for  ten  years ;  in  both 
Mintz's  and  Whitehead's  ^  cases  the  patients  had  suffered  for 
eight  years.  From  the  fact  that  larger  diverticula  occur  in 
the  neck,  the  symptoms  are  usually  acuter  here  than  elsewhere. 
Diverticula  due  to  traction  do  not  as  a  rule  give  rise  to  obstruc- 
tion, and  therefore  are  rarely  fatal  from  that  cause  ;  but  their 
risk  consists  in  the  danger  of  perforation,  and  the  sudden 
onset  of  serious  symjDtoms  due  to  secondary  complications. 

Treatment. — Something  may  be  done  to  temporarily  miti- 
gate the  sufferings  of  the  patient  and  prolong  life,  but  within 
recent  years  a  great  deal  has  been  accomplished  in  the  way 
of  effecting  a  cure.  As  regards  relief,  a  careful  selection  of 
food  should  be  made.  Solids  should  be  avoided  except  when 
they  are  well  minced  and  mixed  up  with  fluid.  By  means  of 
a  tube  the  cavity  should,  if  possible,  be  washed  out  once  a 
day,  so  as  to  prevent  accumulation.  When  such  conservative 
measures  fail,  and  the  patient  shows  signs  of  sinking  from 
starvation,  gastrostomy  must  be  performed.  In  the  case  re 
ported  by  Whitehead,^  the  patient,  otherwise  on  the  verge  of 
death,  lived  for  six  years  after  the  operation.     Berkham  ^  has 

1   Wiener  vied.  WochcnscJirift,  1880,  p.  33. 

^  Langenbeck's  Archiv,  1892,  Bd.  xliii.  Heft  i.  p.  1. 

3  Lancet,  1891,  vol.  i.  p.  11. 

*  Berliner  klin.  Wochenschrift,  1889,  p.  227. 


124  THE   (ESOPHAGUS 

succeeded  in  treating  a  case  with  a  good  result  by  careful 
catheterisation.  The  diverticulum  was  situated  in  the  neck. 
By  using  a  conical  guttapercha  bougie,  which  after  being 
warmed  could  be  bent  to  the  required  shape,  it  was  found 
possible  to  press  on  the  inferior  lip  of  the  orifice  of  the  pouch, 
so  that  by  repeatedly  .passing  and  pressing  the  lip  it  became 
permanently  displaced.  The  result  was  that  fluids  which 
before  had  always  passed  into  the  diverticulum,  now  found 
their  way  freely  and  easily  into  the  canal  of  the  oesophagus 
below. 

The  most  successful  treatment  of  cervical  diverticula  is, 
however,  now  to  be  found  in  total  extirpation.  The  first 
operation  of  this  kind  appears  to  have  been  performed  by  von 
Bergmann.^  The  pouch  ^as  about  the  size  of  a  pear,  occur- 
ring in  a  woman  aged  38.  She  vomited  all  food  almost 
immediately  after  taking  it.  After  the  removal  of  the  sac, 
the  patient  was  completely  cured.  More  recently  Kocher  ^ 
has  successfully  treated  two  cases  in  a  similar  manner  ;  and  in 
April  1893  Butlin^  reported  to  the  Eoyal  Medical  and  Chirurgi- 
cal  Society  of  London  a  case  in  which  he  had  effected  a  com- 
plete cure  by  excision.  Konig*  records  two  cases  in  which 
successful  excision  was  performed  ;  and  Mandach^  removed 
one  from  the  right  side  of  the  neck  of  a  man  who  for  several 
years  had  had  increasing  difficulty  in  deglutition,  and  at  last 
total  obstruction.  In  a  case  reported  by  Mixter,^  a  pouch 
about  the  size  of  an  egg,  and  situated  to  the  left  and  behind 
the  oesophagus,  was  successfully  excised.  Thus  it  may  be  said 
that,  so  far  as  one  is  permitted  to  draw  conclusions  from 
these  five  cases,  the  operation  of  excision  of  a  cervical  diver- 
ticulum is  attended  with  but  little  risk,  and  is  capable  of 
accomplishing  a  perfect  cure. 

For  the  operation  for  excision  of  diverticula  see  Chapter 
XVI.  on  o^Derations  on  the  oesophagus. 

'  Langenbeck's  Archiv,  Bd.  xliii.  Heft  i.  p.  1. 

*  Journal  of  Laryngology  and  Bhinology,  1892,  vol.  vi.  p.  257. 

^  Trans.  Medico-Chirurgical  Spc.  Lond.  1893,  vol.  Ixxvi.  p.  269. 

*  Berliner  hlin.  Wochenschrift,  1894,  No.  42,  p.  947. 

^  Journal  of  Laryngology  and  Bhinology,  1895,  vol.  ix.  p.  285. 
^  Brit.  Med.  Journ.  Epitome,  1895,  vol.  ii.  p.  26. 


DIVERTICULA  125 

Case  XLI. — Pressure  diverticulum  of  the  oesoi^hagus 
situated  in  the  neck. 
A  farmer,  aged  49,  was  admitted  into  the  Birmingham  General 
Hospital.  The  history  given  was  one  of  constantly  increasing  difficulty 
in  swallowing,  extending  over  a  period  of  ten  years.  His  main  symptom 
was  that  food  was  brought  back  in  a  softened  but  undigested  condition  at 
varying  times  after  being  swallowed.  Inspection  and  palpation  of  the 
neck  failed  to  detect  any  abnormality.  An  attempt  to  pass  a  bougie  failed, 
but  the  instrument  was  arrested  seven  inches  from  the  teeth.  Imme- 
diately after  the  endeavom-,  portions  of  an  orange  and  other  food  that  had 
been  taken  some  ht^irs  previously  were  vomited  in  an  undigested  condi- 
tion. He  was  greatly  emaciated,  and  requested  that  an  opening  might  be 
made  in  his  stomach.  He  died  exhausted  three  days  after  the  operation. 
At  the  post  mortem  a  diverticulum  was  found  arising  from  the  oesophagus 
at  its  upper  end.  The  sac  was  of  a  flattened  pear  shape,  four  inches  deep 
from  the  level  of  the  arytenoids,  three  and  a  half  inches  broad,  and  two 
and  a  half  inches  thick  antero-posteriorly.  Mouth  one  inch  in  diameter, 
and  capacity  six  ounces.  On  its  anterior  wall  the  oesophagus  commenced 
an  inch  and  a  half  below  the  base  of  the  arytenoid  cartilages.  When  the 
sac  was  full  of  fluid,  the  slitlike  opening  in  the  oesophagus  was  com- 
pressed and  firmly  closed.  (Thomas  F.  Chavasse,  '  Trans.  Path.  Soc. 
Lond.'  1891,  vol.  xlii.  p.  82.) 

The  subject  of  diverticula  has  been  so  exhaustively  set 
forth  in  an  article  by  Zenker  and  von  Ziemssen  in  their 
Cyclopaedia,'  that  the  reader  is  advised  to  consult  it  for  any 
further  information  than  has  been  given  here.  A  more  recent 
contribution  to  the  subject  will  be  found  in  the  '  Deutsches 
Archiv  fur  Klinische  Medicin,'  ^  by  Huber. 


CHAPTER  XIV 


ABNORMALITIES    {covtitiued) ,        MALFOEMATIONS     OR    DEFORMITIES. 
CONGENITAL  ATRESIA.       CONGENITAL  STENOSIS.       TORSION 

Malformations  or  Deformities. — Some  of  these  are  to  be 
found  in  monstrosities,  but  those  to  be  dealt  with  here  are  only 
such  as  occur  or  exist  in  the  living.  That  malformations  are 
rare  may  be  concluded  from  the  fact  that  Mackenzie,^  in  a 
particularly  exhaustive   article  upon  the  subject,  and  as  the 

'  Vol.  viii.  p.  52.  2  i8g4_  g^|_  iii_  p_  iQ3_ 

5  Diseases  of  the  Throat  and  Nose,  vol.  ii.  p.  217. 


126  THE    (ESOPHAGUS 

result  of  a  searching  investigation  extending  back  to  the  year 
1670,  could  find  no  more  than  sixty-two  recorded  instances  ; 
and  notwithstanding  the  many  more  complete  means  now 
existent  for  reporting  and  collecting  cases,  I  can  only  find, 
since  his  publication  in  1881,  twelve  additional  ones. 

The  malformations  met  with  in  life  are  congenital  atresia 
or  deficiency,  congenital  stricture,  congenital  diverticula,  and 
torsion.  Of  these,  congenital  diverticula  have  already  been 
dealt  with.  Of  the  remainder,  congenital  atresia  or  deficiency 
is  by  far  the  most  common.  Thus  of  my  twelve  cases  nine 
were  of  this  nature.  They  have  been  reported  respectively 
by  Steele,!  Leven,^  Shattock,^  Boisvert,''  Mekins,'^  Machel,*^ 
Vince,'''  Grandon,®  and  Taylor.^  The  remaining  three  were 
two  cases  of  congenital  stricture  by  Turner  ^^  and  Crary,!'  and 
one  of  torsion  by  Monakow.'^ 

Congenital  atresia. — Pathology. — In  these  cases  it  is  usually 
found  that  the  pharynx  or  oesophagus  terminates  in  a  cul-de- 
sac  somewhere  about  the  level  of,  or  a  little  below,  the  cricoid 
cartilage.  Extending  from  this,  for  a  distance  of  about 
an  inch,  is  often  a  fibrous  cord  which  terminates  in  the 
lower  segment  of  the  gullet,  that  part  which  is  connected 
with  the  stomach.  The  part  of  the  oesophagus  continuous 
with  the  stomach  is  usually  normal ;  but  on  tracing  its  channel 
upwards,  it  is  very  frequently  found  connected  by  a  small 
opening  with  the  trachea.  In  all  but  one  case,  that  of  Steele's, 
this  communication  was  found.  In  this  particular  instance 
the  two  segments  of  the  gullet  were  an  inch  and  a  half  apart, 
with  no  cord  or  band  of  connection  between  them.  The  cause 
of  this  defective  condition  of  the  oesophagus,  whether  depen- 
dent  upon  some  disease  in  early  foetal  life  or  some  incom- 

>  Lancet,  1888,  vol.  ii.  p.  764. 

2  Virchow's  Archiv,  1885,  Bd.  cxlv.  p.  553. 

3  Trans.  Path.  Soc.  Lond.  1889,  vol.  xli.  p.  87. 

*  Quoted  by  Shattock.  ^  Ibid. 

•=  Journal  of  Laryngology  and  Rhinology,  1891,  vol.  v.  p.  239. 

'  J3rit.  Med.  Journ.  1893,  vol.  i.  p.  50. 

"  Solis- Cohen,  Annual  of  the    U7iiversal  Medical  Sciences,  1892,  vol.  iv. 

r-25. 

8  Journal  of  Laryngology  and  Rhinology,  1893,  vol.  vii.  p.  232. 

'0  Trans.  Path.  Soc.  Lond.  1885,  vol.  xxxvi.  p.  185. 

"   New  York  Med.  Journ.  1891,  vol.  liv.  p.  50. 

'-'  Journal  of  Laryngology  and  PJdnology,  18*^3,  vol.  vii.  p.  2G6. 


MALFORIMATTONS  ]27 

pleteness  in  the  process  of  development,  I  shall  not  consider 
here ;  the  reader  is  referred  to  Shattock's  full  discussion  of 
the  subject  accompanying  the  record  of  his  case  in  the  Patho- 
logical Society's  '  Transactions,' 

Symptoms.— It  is  not  long  after  the  birth  of  the  child  that 
indications  are  prominently  given  that  there  is  obstruction  in 
the  gullet.  Almost  immediately  after  the  child  takes  the 
breast,  or  has  been  fed  with  milk,  it  vomits,  returning  all  that 
has  been  swallowed ;  so  that  if  it  is  possible  to  collect  what  is 
ejected  it  will  be  found  to  equal  in  quantity  that  given.  In 
some  cases  dyspnoea  supervenes  upon  the  return  of  the  milk, 
due  to  some  of  it  finding  its  way  into  the  larynx.  Although 
no  food  enters  the  stomach,  meconium  may  be  passed. 
The  child  rapidly  emaciates  and  dies.  The  length  of  life 
depends  upon  the  state  of  nutrition  of  the  child.  In 
Leven's  case,  life  was  prolonged  for  eight  days  ;  but  in  the 
majority  of  instances  death  has  occurred  on  the  second  or 
third  day. 

Diagnosis. — The  passage  of  a  bougie  will  at  once  detect 
the  existence  of  obstruction.  As  a  rule  the  instrument  will 
be  found  not  to  pass  much  beyond  the  cricoid  cartilage  ;  that 
is  to  say,  a  distance  of  from  three  to  four  inches  from  the  lips. 
Independently,  however,  of  the  passage  of  a  bougie,  the  sudden 
and  complete  return  of  all  food  will  in  nearly  all  instances 
sufficiently  indicate  the  true  nature  of  the  case. 

Treatment. — Anything  operative  upon  a  child  so  young  is 
of  itself  of  considerable  gravity;  nevertheless,  if  life  is  to 
be  prolonged  it  must  be  by  operation.  At  present  no  other 
alternative  than  such  a  severe  measure  as  gastrostomy  seems 
at  all  reasonable.  The  condition,  however,  itself  is  sufficiently 
grave  to  warrant  it.  Steele  tried  it  in  his  case,  but  death 
ensued  twenty-four  hours  after.  If  it  should  ever  prove 
successful,  then  Holmes's  suggestion  of  cutting  down  upon  the 
upper  cul-de-sac  and  endeavouring  to  get  a  connection  between 
the  two  segments,  might  later  be  considered.  It  must  always 
be  remembered  that  the  unfortunate  complication  of  a 
communication  of  the  lower  segment  with  the  trachea,  which 
exists  in  the  majority  of  cases,  renders  every  endeavour  less 
likely  to  be  successful  than  might  otherwise  be  expected. 


128  THE    (ESOPHAGUS 

Case  XLII. — Congenital  atresia  of  the  oesophagus. 
A.  S.,  aged  24  years,  was  delivered  of  a  female  child.  The  birth  was 
premature,  occurring  at  the  eighth  month  of  pregnancy.  Eespiration  was 
established  with  difficulty.  The  child  suckled  very  imperfectly,  though 
the  mother  had  a  fuU  breast  of  milk.  On  attempting  to  feed  it  with  milk 
and  water  from  a  spoon,  swallowing  took  place ;  but  after  an  interval 
varying  from  a  few  seconds  to  two  or  three  minutes,  the  child  became 
livid  about  the  lips.  Attempts  to  nourish  it  i^er  rectiim  failed.  After  the 
first  passage  of  meconium,  no  action  of  the  bowels  took  place.  The  child 
became  more  feeble  and  emaciated,  and  died  four  days  after  birth.  At 
the  post-mortem  examination,  the  pharynx  was  found  to  end  in  a  cul-de- 
sac,  a  little  below  the  level  of  the  cricoid  cartilage.  The  oesophagus 
terminated  on  the  posterior  surface  of  the  trachea,  about  halfway  between 
the  cricoid  cartilage  and  the  bifurcation.  On  making  an  opening  through 
its  coats,  just  above  its  cardiac  orifice,  a  probe  could  be  passed  upwards 
into  the  trachea.  (Howard  Marsh,  '  Trans.  Path.  Soc.  Lond.'  1876, 
vol.  xxvii.  p.  149.) 

Case  XLIII. — Congenital  atresia  of  the  oeso2:>hagus. 
Mrs.  B.  in  her  first  confinement  gave  birth  to  a  full-time  female  child, 
apparently  quite  strong  and  healthy.  Everything  the  child  took,  either 
from  the  breast  or  spoon,  was  at  once  regurgitated  through  the  nose.  A 
soft  catheter,  when  introduced,  passed  in  five  or  six  inches  ;  but  on  injecting 
milk  through  it,  regurgitation  ensued  immediately,  the  catheter  having 
become  coiled  up  apparently  in  a  cul-de-sac.  The  child  died  about  forty- 
eight  hours  after  birth.  At  the  post  mortem,  the  oesophagus  ended  in  a 
pouchlike  dilatation  an  inch  and  a  half  below  the  laryngeal  orifice.  From 
the  extremity  of  the  pouch  a  fibrous  cordlike  prolongation  could  be  traced 
for  about  two  inches.  A  probe  passed  through  the  cardiac  orifice,  after 
opening  the  stomach,  showed  that  the  gastric  extremity  of  the  oesophagus 
was  represented  by  a  muscular  tube  of  about  the  normal  calibre  below,  but 
becoming  smaller  and  thinner  as  it  passed  uj)wards  behind  the  oesophageal 
pouch  above  mentioned,  and  finally  opening  into  the  trachea  in  the  fibrous 
space  behind  the  cricoid  cartilage  and  the  first  tracheal  ring.  (J.  Foster 
Vince,  '  Brit.  Med.  Journ.'  1891,  vol.  i.  p.  14.) 

Congenital  stenosis. — Tn  1885  Tamer  ^  showed,  at  the 
Pathological  Society  of  London,  a  specimen  of  stenosis  of  the 
lower  end  of  the  gullet,  removed  from  a  child  aged  18  months. 
Besides  this  case  and  one  reported  by  Crary  ^  in  1890,  no  other 
instances  have  apparently  been  recorded  since  those  by  Fagge^ 
and   Wilks,'*  found  quoted  in  most  textbooks  on  the  subject. 

'   Trans.  Path.  Soc.  Lond.  1885,  vol.  xxvi.  p.  185. 
"^  New  York  Med.  Journ.  1891,  vol.  liv.  p.  50. 
^  Guifs  Hospital  Reports,  3rd  series,  vol.  xvii.  p.  413. 
*  See  above,  page  113. 


CONGENITAL   STENOSIS  129 

Wilks's  case  has  already  been  referred  to  under  Dilatation  of  the 
Oesophagus,  the  latter  being  greatly  enlarged  above  the  seat  of 
constriction.  In  von  Ziemssen's  '  Cyclopaedia  of  Medicine ' '  are 
to  be  found  reports  of  three  cases  where  the  stricture  was 
situated  at  the  upper  end  of  the  gullet,  and  two  others  where 
the  stricture— as  in  the  cases  of  Wilks  and  Fagge — was  located 
at  the  lower  part.  Thus  there  only  appear  on  record  eight 
cases  of  this  affection.  With  the  exception  of  Turner's  and 
Crary's  cases,  all  the  patients  lived  to  a  good  age.  The  degree 
of  dysphagia  varied.  Thus  in  two  cases  it  commenced  early, 
in  another  the  patient  was  over  40  years  old  before  he  was 
troubled  with  it.  In  nearly  all,  life  was  easily  maintained 
by  a  careful  attention  to  diet,  and  it  seems  likely  that  in 
Turner's  case,  where  the  child  only  lived  eighteen  months, 
life  might, have  been  prolonged  had  attention  been  paid  to 
the  feeding  earlier  ;  at  least,  such  was  the  opinion  of  the 
author.  Any  indiscretion  in  diet  is  liable  to  invoke  spasm 
around  the  constricted  orifice,  and  hence  for  a  time  increase 
the  difficulty  of  deglutition.  The  passage  of  a  bougie  will  in 
most  cases  determine  the  nature  of  the  obstruction  ;  in  the 
case  of  Turner's  child,  however,  some  doubt  seems  to  have 
existed  as  to  whether  the  bougie  entered  the  stomach. 

The  conclusions  to  be  drawn  from  these  cases  seem  to  be 
that  life  may  be  prolonged  to  comparatively  old  age,  with 
freedom  from  any  material  discomfort,  so  long  as  the  food 
taken  is  carefully  selected,  well  masticated,  slowly  eaten,  and 
either  mixed  with  or  followed  by  fluids.  As  regards  treatment 
of  the  stricture,  Crary's  case  would  suggest  that  good  may 
result  from  its  dilatation  with  bougies.  But  whether  this  is 
likely  to  follow  in  all  cases  is  doubtful,  for  the  conditions 
are  not  comparable  to  such  as  exist  in  cicatricial  stricture. 
Operations,  especially  those  of  a  cutting  character,  are  not 
advisable. 

Case  XLIV. — Congenital  stricture  of  the  oesophagus. 

A  man  aged  21'  years  presented  himself  at  the  Eoosevelt  Hospital 

Dispensary  in  September  1889  with  the  history  of  having  had  difficulty  in 

swallowing  ever  since  birth.     Even  when  a  nursing  infant  the  milk  had 

been  frequently  regurgitated.     At  the  age  of  12  years  he  had  been  troubled 

1  Vol.  viii.  p.  18, 


130  THE    CESOPIIAGUS 

by  frequent  aggravations  of  his  tronble,  extending  over  long  periods.  At 
sucli  times  he  had  been  nnable  even  to  swallow  water,  and  he  became 
so  exhausted  that  he  had  to  remain  in  bed  until  the  stricture  relaxed 
sufficiently  to  allow  of  his  taking  fluids.  Under  ordinary  circumstances, 
ho  said,  lie  had  been  unable  to  take  any  solid  food  except  when  very 
minutely  divided,  and  that  even  then  it  had  become  necessary  for  him 
to  leave  the  table  before. finishing  a  meal  in  order  to  relieve  himself  of 
some  of  the  food  which  he  had  taken.  When  first  seen  at  the  dis- 
pensary he  showed  signs  of  malnutrition  and  was  almost  too  weak  to 
walk.  After  much  difficulty  a  bougie  (No.  20  French)  was  passed  through 
the  strictm-e,  which  was  found  to  be  a  long  one  situated  fourteen  to 
sixteen  inches  from  the  teeth,  diminishing  in  calibre  as  it  approached  the 
orifice  of  the  stomach,  near  which  opening  it  was  evidently  located.  A 
bougie  of  this  size  was  passed  three  times  a  week  for  about  two  months, 
at  which  time  it  passed  quite  easily.  Since  that  time  the  stricture  had 
been  very  gradually  dilated,  imtil  it  would  admit  an  instrument  about  eight 
millimeters  in  diameter.  Only  after  the  first  introduction  was  there  any 
bleeding,  and  that  was  very  slight.  The  resxilt  of  the  treatment  had  been 
very  satisfactory.  He  was  able  to  drink  quite  easily,  and  could  take 
almost  all  kinds  of  solid  food  except  the  firmer  meats.  (George  W.  Crary, 
'  New  York  Med.  Journ.'  1891,  vol.  Hv.  p.  50.) 

Torsion  of  the  oesophagus. — Monakow  ^  reports  an  unusual 
case  of  spasmodic  dysphagia  which  proved  to  be  due  to  torsion 
of  the  gullet  about  its  axis.  The  patient  was  32  years  old,  and 
was  attacked  periodically  with  difficulty  in  swallowing.  Food 
descended  as  far  as  the  sternal  region,  and  was  regurgitated  after 
some  hours.  Death  followed  from  inanition.  At  the  post 
mortem  it  was  found  that  nothing  could  pass  until  the  torsion 
was  redressed.  In  the  case  reported  by  Davy,^  and  already 
referred  to  under  Dilatation,  a  twist  or  volvulus  was  found  in 
the  oesophagus  at  its  cardiac  extremity.  In  order  to  facilitate 
swallov\  ing,  the  patient  used  to  stretch  himself,  and  the  author  s 
opinion  was  that  in  thus  acting  he,  so  to  speak,  undid  the 
twist. 


CHAPTER   XV 

EXTERNAL    INFLUENCES  :    PRESSURE.       PERFORATION.       DISTORTION 

Irrespective  of   diseases  which  may  be  said  to  be  directly 
connected  with  the  wahs  of  the  oesophagus,  there  are  certain 

'  Michael,  Journal  cf  Laryngology  and  EhinoJogy,  1893,  vol.  vii.  p.  2C6. 
-  See  above,  iJage  113 


PRESSURE   FROM    WITHOUT  131 

influences  exercised  upon  it  from  without  which,  from  the 
nature  of  the  symptoms  produced,  are  Hable  to  be  mistaken 
for  an  affection  of  the  tube  itself.  Thus  it  may  be  pressed 
upon,  perforated,  or  distorted. 

Pressure.— The  commonest  cause  of  pressure  is  aneurysm, 
and  among  other  causes  are  enlarged  glands,  tumours, 
abscesses,  a  distended  pericardium,  enlarged  auricles  (Bris- 
towe),  and  backward  dislocation  of  the  sternal  end  of  the 
clavicle. 

Aneurysms  which  cause  pressure  on  the  oesophagus  mostly 
arise  from  the  aorta,  but  in  rare  instances  they  have  been 
connected  with  other  large  neighbouring  vessels. 

The  symptoms  at  the  early  stage,  besides  those  peculiar 
to  the  disease  itself,  are  of  the  nature  of  some  difficulty  in 
swallowing.  This  difficulty,  even  when  at  its  worst,  rarely 
reaches  the  acute  stage  of  that  found  in  stricture  ;  and  the 
fact  that  in  so  many  cases  of  aneurysm  of  the  thoracic  aorta 
there  is  an  absence  of  all  dysphagic  trouble,  shows  that  its 
appearance  in  any  particular  case  must  depend  upon 
cerfain  special  relations  between  the  aneurysm  and  the 
gullet.  That  the  dysphagia  is  never  severe,  finds  probably 
a  correct  explanation  in  two  causes  suggested  by  Knott : ' 
one,  the  absence  of  any  interference  with  the  normal 
peristaltic  action  of  the  muscle  wall ;  and  the  other,  the 
limit  of  the  pressure  to  one  side.  To  these  it  would  seem 
right  to  add  the  ease  with  which  the  gullet,  from  its  loose 
anatomical  connections,  can  adopt  itself  to  any  other  position. 

In  cases  of  prolonged  pressure  from  aneurysm,  attacks  of 
hfemorrhage  may  take  place  ;  these,  only  slight  at  first,  may 
terminate  in  a  fatal  copious  gush.  It  appears  that  the 
process  by  which  perforation  is  brought  about  is  somewhat 
complicated.  Thus  Zenker  ^  states  that  the  pressure  of  the 
aneurysm  causes  a  circumscribed  sloughing  of  the  mucous 
membrane.  When  the  slough  separates  an  ulcer  forms,  and 
by  its  extension  a  communication  is  effected  between  the 
gullet  and  the  aneurysm. 

Pressure  from  enlarged  glands  is  possibly  almost  as  fre- 
quent as  that  from  aneurysm.     By  enlarged  glands  is  meant 

'  Pathology  of  the  (Esophagics,  p.  217. 
^  Cijclopcedla  of  Medicine,  p,  115. 

k2 


132  THE   (ESOPHAGUS 

the  thyroid  in  the  neck,  and  the  bronchial  lymphatic  glands 
in  the  region  of  the  bifurcation  of  the  trachea.  Goitre  was 
in  Mackenzie's  experience  the  commonest  of  all  causes  of 
pressure,  particularly  that  form  of  it  known  as  constrict- 
ing goitre.  A  substernal  bronchocele  may  also  cause  pressure. 
Enlarged  lymphatic -glands,  usually  tubercular,  exist  more 
frequently  in  children  than  in  adults.  Enlargement  of  the 
cervical  glands  may  exercise  pressure  upon  the  oesophagus  in 
the  neck  ;  it  is  more  usual,  however,  for  the  glands  about  the 
root  of  the  lung  to  press  upon  the  gullet  in  that  region. 
Pressure  from  tumours,  such  as  carcinoma,  sarcoma,  lym- 
phoma, and  lympho-sarcoma,  may  take  place  in  any  part  of 
the  course  of  the  gullet.  It  is  more  frequent,  however,  with 
the  exception  of  carcinoma  of  the  thyroid,  for  these  malignant 
growths  to  attack  the  posterior  part  of  the  canal,  taking  their 
origin  from  the  spinal  column.  In  a  case  presented  by  Cahill ' 
to  the  Pathological  Society  of  London,  a  lymphomatous 
tumour  was  situated  between  the  oesophagus  and  the  trachea, 
below  the  level  of  the  cricoid.  It  embraced  the  sides  both  of 
the  gullet  and  the  trachea.  Churton^  records  a  case  of 
sarcoma  of  the  lungs  and  bronchial  glands  causing  stenosis. 

Among  innocent  tumours,  exostosis  of  a  vertebra  is  men- 
tioned by  some  authors  as  having  given  rise  to  compression. 

Pressure  from  abscess  occasionally  occurs  in  cases  of 
spinal  caries.  In  a  case  which  came  under  my  own  observa- 
tion, the  abscess  was  seated  behind  the  upper  part  of  the 
sternum ;  the  child  had  some  little  difficulty  in  swallowing 
both  solids  and  fluids,  always  experiencing  during  the  endea- 
vour a  disagreeable  choking  sensation.  His  most  distressing 
symptoms  were,  however,  connected  with  his  breathing. 
The  case  is  recorded  in  the  '  Annals  of  Surgery.'  ^  A  case  re- 
ported by  Ballot  "*  would  appear  to  have  been  of  a  somewhat 
similar  nature.  Although  there  was  definite  difficulty  in 
deglutition,  and  great  impediment  to  breathing,  the  abscess  at 

'  Note. — It  should  be  stated  that  the  committee  appointed  by  the  society  to 
further  investigate  this  case  reported  subsequently  that  it  believed  the  tuinour 
to  be  a  carcinoma,  and  in  all  probability  to  take  its  origin  in  the  cesophagus. — 
Trans.  Path.  Soe.  Lond.  1891,  vol.  xlii.  p.  91. 

-  Brit.  Med.  Joimi.  1891,  vol.  i.  p.  648.  ^  iggj^  ^^i^  j^.  p.  193, 

■*  Dublin  Medical  Press,  vol.  vii.  p.  23. 


PRESSURE   FllOxM    WITHOUT— PEKFORATIOX  1:33 

the  post  morfcom  was  proved  to  be  located  rather  behind  the 
pharynx  than  the  oesophagus,  and  so  exercised  pressure  upon 
the  larynx  and  this  part  of  the  alimentary  canal.  Hay  den  ^ 
published  a  case  where  an  abscess  was  situated  between  the 
trachea  and  the  oesophagus.  Although  this  is  quoted  as  an 
illustration  of  external  pressure,  it  was  believed  in  reality  to 
have  had  its  origin  in  an  ulcer  of  the  oesophagus,  which  had 
subsequently  led  to  suppuration  in  the  perioesophageal  con- 
nective tissue. 

It  must  be  remembered  that  in  nearly  all  cases  of  com- 
pression of  the  oesophagus  in  the  neck  and  in  the  upper  part 
of  the  thorax,  the  dysphagia  will  be  associated  with  symptoms 
of  dyspnoea.  The  amount  of  pressure  sufficient  to  produce 
difficulty  of  swallowing  will  almost  certainly  produce  greater 
difficulty  in  breathing.  This  association  of  dyspnoea  wath 
dysphagia  wdll  in  many  cases  serve  to  distinguish  between 
obstruction  the  result  of  external  influences,  and  that  arising 
from  disease  of  the  canal  itself.^ 

Perforation. — Many  of  the  causes  already  given  as  produc- 
tive of  pressure  may  in  their  later  stages  result  in  perfora- 
tion. Aneurysm,  as  indicated  above,  gives  rise  to  haemorrhage  ; 
perforation  by  external  malignant  growths  may  cause  a  like 
symptom.  Tubercular  glands  in  the  process  of  suppuration 
may  adhere  to  the  walls  of  the  gullet,  and  finally  ulcerate 
into  its  canal.  Voelcker  ^  has  recorded  such  a  case,  and  in 
his  paper  he  states  that  out  of  2,504  post  mortems  performed 
at  the  Hospital  for  Sick  Children,  he  was  able  to  find  three 
other  cases  of  caseous  glands  rupturing  into  the  gullet.  In 
Voelcker' s  case  no  symptoms  existed  during  life  to  indicate 
the  existence  of  perforation.  In  two  out  of  the  three  collected 
cases,  the  glands  had  also  ruptured  into  the  air  passages. 

The  same  author  ''  reports  an  instance  of  a  boy,  aged  6 
years,  who  for  some  time  had  suffered  from  empyema.  After 
the  thoracic  cavity  was  opened,  it  was  found  that  fluids 
taken  by  the  mouth  found  their  way  out  through  the 
artificial  thoracic  opening.     At  the  post  mortem  two  openings 

'  Trans.  Path.  Soc.  Dublin,  1865,  p.  143. 

^  See  page  71  for  exceptions  in  cases  of  carcinoma  of  the  oesophagus. 

=*  Trans.  Path.  Soc.  Lond.  1891,  vol.  xlii.  p.  87. 

*  Medical  Press  and  Circular,  1890,  vol.  ii.  p.  629. 


134 


THE   (ESOPHAGUS 


were  found  in  the  gullet,  one  opposite  the  eighth  dorsal  vertebra 
and  the  other  a  little  below  it. 

Distortion. — It  is  rarely  that  the  oesophagus  is  so  bent  upon 
itself  that  symptoms  of  obstruction  show  themselves.  Hacker  ' 
has  investigated  the  effects  of  lateral  curvature  of  the  spine 
upon  the  oesophagus.  His  paper  is  illustrated,  and  he  shows 
how  in  two  out  of  the  five  figures  given,  difficulty  is  encoun- 
tered in  the  passage  of  a  bougie.  As  might  be  expected,  it  is 
where  the  primary  and  compensatory  curves  are  acute. 


CHAPTEE   XVI 


OPERATIONS 


1.  introduction  of  bougies, 
forceps,  probangs,  ex- 
tractors, &c. 

2.  internal  (esophagotomy 

3.  electrolysis 

4.  external   (esophagotomy 

(cervical) 


5.  external      (esophagotomy 

(thoracic) 

6.  (ESOPHAGOSTOMY 

7.  EXCISION    OF    diverticula 

8.  oesophagoplasty 

9.  (esophagectomy 


The  operations  to  be  described  here  are  those  only  which 
directly  implicate  the  gullet  itself.  Although  gastrotomy  and 
gastrostomy  are  both  operations  performed  as  a  part  of  the 
treatment  of  certain  diseases  affecting  this  region,  they  will 
not  be  dealt  with  here,  but  wiJl  be  found  fully  described  in  the 
chapter  devoted  to  operations  upon  the  stomach,  at  the  con- 
clusion of  the  section  which  deals  with  the  surgical  affections 
of  that  region. 

1.  Introduction  of  bougies,  forceps,  probands,  extractors, 
&c. — For  the  passage  of  instruments  the  patient  should,  if 
possible,  be  seated  on  a  chair  or  propped  up  in  bed,  and  the 
surgeon  should  stand  in  front  or  on  the  patient's  right  side. 
The  head  should  be  slightly  thrown  back,  and  securely  held  by 
an  assistant.  The  arms  also,  especially  in  the  case  of  children, 
should  be  secured  either  by  a  third  assistant  or  enclosed  in  a 
binder  passed  round  the  chest.  To  keep  the  mouth  open  a 
gag  may  be  used,  and  preferably  an  ordinary  wine-bottle  cork. 


Wiener  mcd.  Wochenschrift,  1887,  p.  1494. 


IXTl>()l)i;CTl()X    OF    LXteTJlUiMKXTS  1;).> 

When  possible  and  deemed  advisable,  the  patient  sliuuld  be 
{;()t  to  swallow  a  little  olive  oil  or  glycerine ;  failing  this  the 
instrument  should  be  smeared  with  some  lubricant.  Either 
by  friction  or  hot  water  it  should  be  previously  warmed. 

In  the  case  of  pliable  instruments,  these  should  be 
previously  bent  to  the  required  curve  and  then  taken  in  the 
right  hand  of  the  surgeon  and  carefully  conducted  to  the  back 
of  the  pharynx.  The  end  of  the  tongue  secured  by  the 
operator  between  the  fingers  and  thumb  of  his  left  hand 
covered  with  a  towel  or  piece  of  lint,  \^ill  help  to  draw  the 
larynx  forwards,  and  give  a  means  also  of  somewhat  steady- 
ing the  patient's  head.  In  some  cases  it  will  be  found  better 
to  depress  the  tongue  with  the  finger,  and  guide  the  end  of  the 
instrument  over  the  glottis.  Immediately  the  instrument 
touches  the  back  of  the  pharynx,  the  patient  will  retch ;  but 
as  long  as  there  is  no  real  difficulty  in  respiration,  indicative 
of  its  being  within  the  larynx  instead  of  within  the  gullet, 
it  should  be  steadily  pushed  on.  Further  aid  to  its  passage 
will  be  obtained  by  inducing  the  patient  to  swallow.  By  so 
doing  a  normal  peristaltic  action  takes  place,  which  will  be 
felt  either  to  carry  the  instrument  on,  or  materially  facilitate 
its  downward  movement  on  pressure.  Solis-Cohen  '  finds  that 
in  dilating  strictures  in  the  upper  part  of  the  gullet,  the 
passage  of  bougies  is  much  facilitated  by  drawing  the  larynx 
and  trachea  forwards  betw^een  the  thumb  and  fingers  of  the 
disengaged  hand  at  the  moment  that  the  obstruction  is  reached 
by  the  dilating  instrument. 

Gentleness  must  in  all  cases  be  exercised.  Any  hitch  in 
the  progress  of  the  instrument  should  not  be  overcome  by 
force,  but  time  should  be  allowed  for  the  subsidence  of  spasm. 
If  advance  is  still  impeded  the  instrument  should  be  with- 
drawn, and  the  endeavour  renewed. 

The  question  of  the  admhiistration  of  an  anaesthetic  has 
already  been  discussed,  and  rather  than  occupy  space  here  by 
repeating  the  arguments  for  and  against  its  administration, 
the  reader  may  be  referred  back  to  page  28. 

It  is  useful  to  remember,  in  the  introduction  of  bougies  or 
tubes,  that  in  the  adult  the  distance  between  the  incisor  teeth 

'  Journal  of  Laryngology  and  Ehinology,  1887,  vol.  i.  p.  106. 


136  THE   OESOPHAGUS 

and  the  orifice  of  the  oesophagus  is  from  five  to  six  inches,  and 
the  length  of  the  gullet  itself  from  nine  to  ten  inches.  Hence 
the  cardiac  orifice  will  be  distant  from  the  teeth  from  fourte(  n 
to  sixteen  inches. 

2.  Internal  oesophag-otomy. — The  cutting  of  a  stricture  from 
within  the  canal  necessitates  the  passage  of  the  cutting 
instrument,  or  cesophagotome,  through  the  contracted  portion. 
Hence,  prior  to  its  introduction,  it  must  be  ascertained  by 
the  passage  of  bougies  that  the  channel  is  sufficiently  large. 
There  are  different  forms  of  oesophagotome,  but  the  common 
feature  underlying  all  is  the  presence  of  one  or  two  concealed 
blades  located  at  the  distal  extremity  of  the  instrument,  and 
capable  of  being  projected  to  the  required  distance  by 
mechanical  contrivances  placed  in  the  handle. 

In  the  manner  already  described  for  the  introduction  of 
bougies  &c.,  the  instrument  is  passed  down  the  cesophagus 
until  it  is  judged  that  the  bulbous  cutting  extremity  is  beyond 
the  seat  of  stricture.  The  blade  or  blades  is  or  are  then  made 
to  project,  and  by  a  rapid  pull  outwards,  of  sufficient  distance 
to  traverse  the  length  of  the  stricture,  the  latter  is  divided. 
The  process  may  be  repeated  two  or  more  times  if  thought 
necessary.  To  prevent  any  union  of  the  cut  surfaces,  bougies 
should  be  passed  within  the  course  of  a  day  or  two.  For 
dangers  in  connection  with  this  operation  see  page  93. 

3.  Electrolysis. — Considerable  use  has  been  made  of  this 
method  of  treatment  in  strictures  of  the  oesophagus  ;  and,  as 
already  indicated  in  discussing  that  part  of  the  subject, 
much  success  has  attended  its  employment.  I  cannot  do 
better  than  quote  Steavenson  ^  on  the  '  Uses  of  Electrolysis 
in  Surgery,'  for  the  manner  of  putting  this  method  into 
practice. 

'  A  long  flexible  electrode,  like  an  ordinary  oesophageal 
bougie,  is  required,  to  which  can  be  attached  olivary  metal 
ends  of  various  sizes,  as  in  the  case  of  some  of  the  electrodes 
used  for  stricture  of  the  urethra  and  rectum.  The  electrode 
is  connected  with  the  negative  pole  of  the  battery,  that  con- 
nected with  the  positive  pole  being  placed  on  some  indifferent 
part  of  the  body.  A  current  strength  of  five  milliamperes  is 
generally  employed,  and  the  current  allowed  to  flow  for  fifteen 

'  Page  91. 


EXTEI^XAL   (KSOrilAGOTOMY  137 

or  twenty  minutes,  unless  the  electrode  passes  the  obstruction 
in  a,  shorter  time.  It  will  be  found,  as  in  the  case  of  strictures 
in  other  jmrts,  that  recontraction  does  not  take  place  so 
rapidly  as  after  dilatation,  and  that  usually  after  a  week's 
interval  a  bougie  one  size  larger  can  be  passed  than  that  used 
on  the  former  occasion.  A  perforated  electrode  has  been  used 
which  will  pass  over  a  celluloid  guide  so  as  to  diminish  the 
risk  of  its  passing  into  a  pouch  by  the  side  of  the  oesophagus, 
or  of  its  decomposing  laterally  too  much  of  the  cancerous 
tissue  of  a  malignant  stricture,  and  by  this  means  making 
an  opening  into  the  posterior  mediastinum.  The  guide  is 
sufficiently  small  to  pass  through  the  stricture  and  thus  direct 
the  passage  of  the  electrode.  As  with  other  forms  of  treat- 
ment of  oesophageal  stricture,  electrolysis  gives  more  prospect 
of  success  with  the  fibrous  variety  than  with  the  malignant.' 

Campbell,^  in  several  cases  which  he  successfully  treated, 
gradually  increased  the  strength  of  the  current  from  five  to 
twenty-five  milliamperes.  Painter,^  another  successful  opera- 
tor, placed  the  positive  pole  within  the  constriction  ;  and 
in  the  case  which  he  records,  the  application  was  made  three 
times  a  week.  After  the  fifteenth  application  meat  and  bread 
could  be  swallowed.  After  twenty-five  applications,  lasting 
three  months,  the  patient  could  eat  without  regurgitation  so 
long  as  the  meat  was  finely  cut  up. 

4.  External  cesophagotomy  (cervical). — This  operation  is 
usually  performed  on  the  left  side  of  the  neck,  except  in  such 
cases  where  the  position  of  the  impacted  body  suggests  that 
removal  would  be  more  easily  effected  on  the  right. 

The  patient  is  placed  in  the  supine  position,  with  the 
shoulders  slightly  raised  and  the  head  thrown  back  and 
rotated  to  the  right  side.  The  side  of  the  neck  is  shaved  free 
of  any  hairs,  and  Ihe  skin  properly  cleansed  and  prepared  as 
for  any  ordinary  antiseptic  operation.  The  surgeon,  standing 
on  the  left  side  of  the  patient,  ascertains  the  necessary  land- 
marks :  the  upper  border  of  the  thyroid  cartilage,  the  sterno- 
clavicular articulation,  and  the  anterior  border  of  the  sterno- 
mastoid.  The  skin  being  steadied  between  the  fingers  and 
thumb  of  the  left  hand,  an  incision  is  carried  along  the  margin 

'  Journal  of  Laryngology  and  lilunology,  1892,  vol.  vi.  p.  573. 
2  Ibid.  1888,  vol.  ii.  p.  418. 


138  THE   ESOPHAGUS 

of  the  anterior  border  of  the  sterno-mastoid  from  about  three- 
quarters  of  an  inch  above  the  sterno-clavicular  articulation  to 
the  upper  border  of  the  thyroid  cartilage.  By  this  incision 
the  skin,  superficial  fascia,  and  platysma  myoides  are  divided, 
together  v^^ith  possibly  some  superficial  veins;  these  latter 
should  be  at  once  secured,  and  if  by  any  chance  it  is  observed 
before  making  the  incision  that  the  line  is  crossed  by  either 
the  anterior  or  external  jugular,  these  should  be  first  double- 
ligatured  and  then  divided. 

The  next  stage  of  the  operation  consists  in  a  careful  deep 
dissection  down  to  the  gullet.  This  should  be  effected  mostly 
by  snipping,  teasing  or  tearing  the  parts  asunder,  and  not  by 
any  free  cutting. 

As  soon  as  the  anterior  border  of  the  sterno-mastoid  is 
exposed  it  should  be  hooked  aside,  and  similarly  the  carotid 
sheath — with  its  vessels  and  nerves  when  sufficiently  isolated — 
should  be  drawn  outwards  and  included  with  the  muscle  in 
the  grasp  of  the  same  retractor.  The  omo-hyoid  muscle, 
which  crosses  the  space  at  its  upper  part,  if  it  cannot  be 
hooked  aside,  must  be  divided  as  near  as  possible  to  its  attach- 
ment to  the  hyoid  bone,  so  as  to  avoid  any  interference  with 
its  nerve  supply  through  the  descendens  noni.  The  sterno- 
thyroid and  sterno-hyoid  together  with  the  thyroid  gland  must 
be  drawn  slightly  inwards.  To  facilitate  this  lateral  retraction 
of  parts,  the  head  should  be  slightly  flexed.  With  a  little 
further  careful  dissection  through  the  deep  fascia,  the 
oesophagus  will  be  reached  lying  beneath  the  trachea,  which 
must  also  be  drawn  gently  to  the  opposite  side  in  order  to 
better  expose  the  former.  In  this  latter  part  of  the  dissection 
the  thyroid  arteries  should  be  avoided,  or,  if  division  is  necessary 
to  gain  freer  access,  they  should  be  first  secured.  The  re- 
current laryngeal,  which  runs  upwards  between  oesophagus  and 
the  trachea,  must  be  carefully  avoided  ;  any  injury  to  it  would 
lead  to  impairment  of  the  voice. 

The  final  stage  of  the  operation  consists  in  opening  the 
gullet.  If  the  operation  be  for  an  impacted  body  which  can 
be  easily  felt,  no  further  guide  is  necessary  for  the  incision. 
If,  on  the  other  hand,  the  oesophagus  is  in  its  normal  flaccid 
condition,  a  bougie  or  sound  should  if  possible  be  introduced 
by  the  mouth  and  made  to  project  at  the  point  at  which  the 


JCXTEHNAL   (]{KOi'lIA(iOTOM Y  im 

canal  is  to  be  opened.  "With  a  sharp  scalpel  the  point  of  the 
projecting  instrument  is  cut  down  upon  and  a  small  longi- 
tudinal incision  made.  If  no  instrument  can  be  inserted, 
then  the  walls  of  the  oesophagus  should  be  secured  at  two 
points  by  two  pairs  of  forceps,  the  parts  between  them  drawn 
shghtly  forwards,  and  the  knife  carefully  but  quickly  plunged 
into  the  canal.  The  incision  can  be  enlarged  by  snicking  with 
a  pair  of  scissors  in  an  upward  or  downward  direction,  or 
dilating  with  the  finger  or  a  pair  of  dressing  forceps.  To 
secure  the  opening,  the  edges  may  be  transfixed  with  a  silk 
suture,  or  held  with  two  pairs  of  artery  forceps.  Any 
heemorrhage  is  not  serious. 

Some  difference  of  opinion  exists  as  to  the  advisability 
of  closing  the  oesophageal  wound.  If  it  is  decided  to  do 
so,  the  mucous  membrane  should  be  stitched  separately.  If 
the  muscle  wall  be  included  in  the  same  stitch,  there  is  a 
greater  danger  of  the  sutures  cutting  through.  The  external 
wound  may  be  closed  for  a  considerable  extent ;  and  to  remove 
the  possibility  of  such  serious  consequences  as  would  ensue 
from  any  leakage  from  the  oesophagus,  a  small  drainage  tube 
should  lead  from  the  deepest  part  to  the  surface  at  the  lower 
end  of  the  wound  ;  or  no  attempt  should  be  made  to  close  the 
wound  which  is  stuffed  with  iodoform  gauze.  Either  tube  or 
stuffing  may  be  removed  in  the  course  of  a  few  days  if  all 
seems  doing  well.  When  the  patient  is  returned  to  bed,  it  is 
advisable  to  limit  the  movement  of  the  head  as  much  as 
possible,  either  by  the  way  in  which  the  bandages  are  applied, 
or  by  placing  sandbags  on  each  side  of  the  head. 

If  the  patient's  strength  wiU  admit,  all  nourishment  for 
some  days  should  be  given  by  nutrient  enemata ;  but  if  more 
food  is  required  than  can  be  thus  administered,  it  should  be 
given  by  the  passage  of  a  tube  carefully  introduced  down  the 
gullet. 

5.  External  cesophagotomy  (thoracic). — The  operation  of 
intrathoracic  cesophagotomy  practised  by  Portarca  '  on  the 
dead  subject,  and  proposed  by  him  for  cases  of  impacted  foreign 
body  in  the  mediastinal  portion  of  the  gullet,  is  thus  described  : 
'  The  body  being  turned  over  on  the  belly,  a  vertical  incision, 
between  five  and  six  inches  in  length,  the  middle  of  which  cor- 

'  Brit.  Med.  Joiirn.  Epitome,  1894,  vol.  ii.  p.  79. 


UO  THE   (ESOPHAGUS 

responds  to  the  fourth  dorsal  spine,  is  made  midway  Letw^een 
the  internal  border  of  the  scapula  and  the  spines  of  the  dorsal 
vertebrae.  The  following  structures  are  divided  in  succession  : 
the  aponeurosis  of  the  trapezius,  and  at  the  lower  part  of  the 
wound  some  of  its  muscular  fibres ;  the  aponeurosis  and  lower 
fibres  of  the  rhomboideus  major,  the  aponeurosis  between  the 
two  serrati  muscles ;  then,  after  separation  of  the  sacro-lum- 
bales  from  the  longissimus  dorsi,  the  transversalis  colli.  The 
third,  fourth,  and  fifth  ribs  having  been  thus  exposed,  a  piece  of 
bone  about  an  inch  in  length  is  removed  from  each,  the  internal 
section  of  each  rib  being  close  to  the  transverse  process  of  the 
corresponding  vertebra.  The  pleura  is  now  carefully  stripped 
from  the  inner  fragments  of  the  ribs  and  the  front  of  the  spine, 
and  the  vena  azygos  exposed,  in  front  of  which  will  be  seen  the 
oesophagus  at  a  depth  of  four  inches  from  the  wound  of  the  skin.' 
Weir  ^  reports  '  having  rehearsed  on  the  cadaver  the  opera- 
tion, revived  by  Qiienu,  of  resecting  the  upper  left  ribs  pos- 
teriorly.' Not  only  does  this  method  readily  expose  the 
oesophagus,  but  it  admits  of  the  left  bronchus  being  reached 
without  invading  the  pleural  cavity.  For  a  full  description  of 
the  operation,  Quenu's  paper  ^  should  be  consulted. 

6.  OEsophagostomy. — The  steps  of  the  operation  as  far  as 
to  and  including  the  opening  of  the  oesophagus  are  the  same 
as  above  described.  The  edges  of  the  oesophageal  wound  are 
then  caught  up  by  forceps,  and  by  means  of  gentle  traction 
united  by  a  silk  stitch  or  two  to  the  margins  of  the  skin. 
The  depth  of  the  gullet  will  not  admit  of  too  intimate  a  con- 
nection between  it  and  the  surface,  it  should  therefore  only  be 
sufficiently  secured  to  admit  of  a  moderately  easy  and  safe 
insertion  of  the  tube.  This  tube — which,  from  its  partial 
resemblance  to  a  tracheotomy  one,  might  be  designated  an 
cesophagotomy  tube — measures  about  three  inches  in  length 
below  the  bend  and  about  one  inch  above  it.  To  its  short  end 
is  fixed  a  shield,  so  that  after  the  introduction  of  the  tube  into 
the  gullet,  it  is  secured  in  position  by  tapes  tied  round  the 
neck.  As  in  the  operation  of  tracheotomy,  any  undue  gaping 
of  the  wound  above  and  below  the  tube  may  be  brought 
together  by  a  few  stitches.     In  feeding  the  patient  a  much 

'  Naiu  York  Med.  Jourii.  1891,  vol.  liv.  p.  639. 
-  Bcvue  da  Chlrurrjie,  1891,  p.  265. 


EXCISION   OF   DIVERTICULA  141 

lonp;er  tube  and  one  of  a  less  calibre  may  l)e  inserted  tlirougli 
the  fixed  one,  so  as  to  make  sure  that  none  of  the  li(j[iud  material 
given  finds  its  way  into  the  pericesophageal  tissues.  In  the 
event  of  the  so-called  '  oesophagotomy  tube '  not  being  used, 
care  must  be  taken  in  the  insertion  of  the  feeding  tube  that 
it  does  not  make  its  way  into  the  soft  tissues  instead  of  into 
the  oesophagus.  Solis-Cohen  '  quotes  an  instance  which  came 
under  his  observation,  where  a  rigid  stomach  tube  had  been 
passed.  Instead  of  finding  its  way  into  the  gullet,  it  went 
down  into  the  mediastinum.  The  accident  was  undiscovered 
until  after  the  death  of  the  patient  on  the  following  day. 

The  remaining  operations  have  been  performed  too  rarely 
to  admit  of  any  precise  details  being  laid  down  as  to  their 
execution.  They  have  been  limited  so  far  to  special  circum- 
stances affecting  each  case,  and  to  the  ingenuity  of  the  surgeon 
operating.  Some  guidance,  however,  may  be  gained,  in  any 
subsequent  attempts,  by  a  brief  and  general  summary  of  the 
steps  taken  in  the  few  cases  recorded,  and  where  the  surgeon 
himself  has  described  the  operation  performed  or  made 
suggestions  in  reference  to  it. 

7.  Excision  of  diverticula. — The  preliminary  steps  for  the 
exposure  of  the  diverticulum  are  the  same  as  those  given  for 
the  performance  of  external  oesophagotomy.  The  pouch  is 
then  freed  from  all  connections  with  surrounding  parts,  and 
its  neck  or  junction  with  the  gullet  carefully  traced.  The 
severance  of  the  sac  from  the  main  channel  may  be  effected 
in  one  of  two  ways.  It  may  be  cut  through,  the  edges  of  the 
mucous  membrane  of  the  gullet  being  then  stitched  together, 
as  successfully  performed  by  von  Bergmann,^  or  the  whole 
thickness  of  the  oesophageal  wall  united,  as  also  successfully 
accomplished  by  Butlin.'^  Instead  of  cutting  the  neck  of  the 
sac,  it  may  be  secured  by  two  ligatures  placed  apart,  and 
division  effected  by  the  thermo-cautery  applied  between  them. 
Kocher  *  successfully  treated  two  cases  by  this  method.  The 
treatment  of  the  external  wound  will  probably  depend  upon 
the  surgeons'  individual  feelings  with  regard  to  the  wisdom  of 

'  International  Encydopccclia  of  Surgery,  vol.  vi.  p.  37. 

^  Archiv  fur  Klin.  Chir.  Bd.  xliii.  Heft  i.  p.  1. 

3  Trails.  Med.-Chir.  Soc.  Loncl.  1893,  vol.  Ixxvi.  p.  2C9. 

*  Solis-Cohen,  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  'v.  F—  33. 


142  THE   (ESOPHAGUS 

completely   closing   it   or   not.       Botli   von   Bergmann    and 
Koclier   partially    closed,    stuffing   the  remaining   part   with 
iodoform  gauze.     The  after  treatment  of  these  cases  will  be 
pretty  much  a  matter  for  the  judgment  of  the  surgeon.      It 
would  seem  advisable,  however,  to  nourish,  if  possible,  entirely 
by  the   rectum.      In  von  Bergmann's  case   the  patient  was 
given  water  immediately  after  the  operation.     On  the  sixth 
day  milk  escaped  from  the  wound.     A  small  fistula  resulted, 
but  it  was  subsequently  closed  by  means  of  the  actual  cautery. 
8.  (Esophagoplasty. — Von  Hacker  '  has  described  an  opera- 
tion for  the  reconstruction  of  the  canal  after  complete  resection 
of  a  portion  of  the  oesophagus  for  carcinoma.      The  operation 
is  performed  in  two  stages.     After  excision  of  the  part,  two 
flaps  of  skin  are  raised  on  each  side  ;  these  are  carried  back- 
wards, and  united  above  and  below  to  the  cut  ends  of  the 
oesophagus.      This  constitutes  the  first  stage.      The  second 
consists  of  detaching  these  flaps  from  their  bases  and  folding 
them   over  so  as  to  complete  the  canal.      The  stitching  is 
completed  around  the  oesophagus  above  and  below,  and  they  are 
united  together  down  the  median  line.     Von  Hacker  completed 
the  first  stage  in  a  patient  aged  66  years,  but  before  reaching 
the  second — which  is  recommended  to  be  performed  some  two 
or  three  weeks  later— the  patient  died  of  heart  failure.  Poulsen, 
who  has  also  performed  the  operation,  was  more  successful, 
being  able  to  complete  both  stages  of  the  operation.      The 
wound  healed,  leaving  only  a  slight  defect  below  from  a  circum- 
scribed gangrene  of  the  lower  angle  of  the  flaps.     The  patient, 
however,   succumbed  later  to  pneumonia.     In  von  Hacker's 
paper  there  are  diagrams  of  the  operation  which  better  eluci- 
date the  steps  in  its  performance. 

9.  (Esophagectomy. — The  performance  of  this  operation  in 
the  neck  involves,  in  the  first  place,  the  free  exposure  of  the 
gullet  by  the  same  incision  as  already  given  for  external 
cesophagotomy  ;  and,  in  the  second,  the  freeing  of  that  portion 
of  the  implicated  gullet  from  the  parts  around,  and  its  excision. 
The  lower  end  of  the  canal  is  then  brought  out  at  the  external 
wound,  and  secured  there  by  stitches  to  the  skin.  The  chief 
difficulties  of  the  operation  are  connected  with  the  excision  of 

'  Cenfralhlatt  far  Chirurgic,  1891,  No.  7,  p.  121. 


(K80PTIA0ECT0MY  143 

the  afTcctod  part,  and  its  greatest  dangers  are  in  shock  and 
subsequent  septic  mischief  about  the  wound. 

Endothoracic  resection  has  been  proposed  by  J.  Nassiloff,^ 
and  the  directions  for  the  operation  as  quoted  by  Sohs-Cohen 
are  the  following  :  '  An  incision  through  all  the  soft  tissues 
is  made  parallel  to  the  internal  border  of  the  scapula,  seven 
to  nine  centimeters  from  the  line  of  the  spinous  processes. 
Two  other  incisions  are  made  at  the  two  extremities  of  the 
first  one.  The  flap  being  detached,  four  ribs  are  resected 
one  after  the  other.  The  pleura  is  carefully  separated  from 
the  ribs,  and  entrance  is  thus  made  at  the  posterior  mediasti- 
num. The  oesophagus  is  now  to  be  isolated,  an  oesophageal 
sound  being  introduced  first  if  desired  or  if  required,  and 
raised  on  a  soft  hook.  The  oesophagus  is  secured  by  ligatures 
placed  above  the  neoplasm  and  below  it,  the  requisite  portion 
is  resected,  and  the  ends  of  the  gullet  united  by  suture  after 
the  method  of  Czerny.  If  the  neoplasm  is  very  extensive  it  is 
proposed  to  simply  cut  the  oesophagus  and  unite  its  inferior 
extremity  to  the  skin  by  suture.  The  final  step  of  the  opera- 
tion consists  in  re-covering  the  wound  with  the  flap  of  soft 
tissues. 

'  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  iv.  G— 38. 


PAET   II 

THE    STOMACH 


CHAPTER  XYII 

SURGICAL    ANATOMY    AND    PHYSIOLOGY 

Surgical  Anatomy. — Unlike  the  (Desophagus,  which  main- 
tains a  fixed  position,  the  stomach  varies  somewhat  in  its 
relations  according  to  its  degree  of  distension.  The  most 
fixed  point  is  at  its  junction  with  the  cesophagus  ;  and  where, 
by  its  other  extremity,  it  becomes  continuous  with  the  bowel, 
it  is  only  loosely  secured  by  the  lesser  or  gastro-hepatic 
omentum.  This  same  fold  of  membrane  extends  along  the 
upper  or  lesser  curvature  of  the  viscus,  and,  passing  to  be 
attached  to  the  liver  above,  tends  to  hold,  as  by  a  sling,  all  that 
part  of  the  organ  to  the  right  of  the  oesophageal  opening. 
The  left  extremity  is  further  secured  by  two  other  folds  of 
membrane.  One,  the  gastro-phrenic  ligament,  passes  up  to 
the  diaphragm  ;  while  the  other,  the  gastro-splenic  ligament, 
connects  it  with  the  spleen.  The  lower  or  greater  curvature 
has  passing  from  it  downwards  the  great  omentum.  This 
latter,  being  in  its  normal  condition  unattached  below,  allows 
of  considerable  freedom  of  movement  of  the  dependent  portion 
of  the  stomach. 

External  relations. — The  cardiac  orifice  of  the  stomach 
corresponds  posteriorly  to  a  point  slightly  to  the  left  and 
below  the  ninth  dorsal  spine,  and  anteriorly  to  a  point  jnst 
below  the  junction  of  the  seventh  costal  cartilage  with  the 
sternum  on  the  left  side.  The  pylorus  corresponds  to  a  point 
close  to  the  extremity  of  the  eighth  rib  on  the  right  side. 
When   distended,  the    stomach   comes   in   contact   with   the 

L 


146  THE    STOMACH 

abdominal  parietes  about  two  inches  below  the  ensiform 
cartilage.  It  occupies  the  left  hypochondriac  and  epigastric 
regions,  encroaching  slightly  upon  the  right  hypochondrium. 

Deej)  relations. —  The  pylorus  and  the  upper  part  of  the 
anterior  surface  are  overlapped  by  the  liver,  the  latter  region 
coming  in  contact  also  with  the  diaphragm,  while  the  former 
touches  in  some  case's  the  neck  of  the  gall  bladder.  Posteriorly 
the  stomach  rests  upon  the  pancreas,  the  large  abdominal 
vessels,  and  the  solar  plexus,  the  membranous  transverse 
meso-colon  intervening.  By  its  left  extremity  it  is  in  contact 
with  the  spleen,  and  close  to  its  lower  or  greater  curvature 
courses  the  transverse  colon. 

Variations  in  jjosition. — The  comparative  looseness  of  the 
connections  of  the  stomach  renders  it  liable  to  considerable 
alterations  in  its  position  from  various  causes.  In  the  nor- 
mal state  this  varies  during  the  process  of  digestion.  When 
distended  it  rotates  about  its  transverse  axis,  the  greater  cur- 
vature being  raised  to  the  front,  while  the  anterior  surface  is 
made  to  look  forwards  and  upwards.  In  this  condition  the 
stomach  comes  in  contact  with  the  parietes.  "When  empty 
and  contracted,  it  lies  back  on  the  pancreas,  giving  rise  to  the 
hollow  in  the  epigastric  region  of  the  parietes  called  the  yit  of 
the  stomach. 

In  certain  abnormal  or  diseased  conditions,  the  position  of 
the  stomach  undergoes  considerable  alteration.  Thus  disten- 
sion of  the  chest  with  fluid  will  depress  the  viscus,  while  a 
similar  condition  of  the  abdominal  cavity  will  press  it  upwards. 
It  may  also  be  caused  to  occupy  a  lower  position  by  being 
dragged  down  by  an  omental  hernia ;  or  pressed  down  by  tight 
lacing.  Disease  of  the  organ  itself  will  produce  variations. 
Thus  tumour  of  the  pylorus  may  cause  that  part  to  sink 
considerably  below  its  normal  position,  and  obstruction  at  the 
same  situation  will  so  increase  the  dimensions  of  the  stomach 
that  it  will  occupy  an  extensively  increased  area. 

Structure. — The  walls  of  the  stomach  are  composed  of  four 
layers  intermediate  in  thickness  between  those  of  the  oeso- 
phagus and  the  intestines  :  an  external  serous  coat  consisting 
of  peritoneum,  an  internal  mucous  lining,  and  an  intermediate 
muscular  coat ;  between  the  mucous  membrane  and  the 
muscle   is   a   distinct   layer   of   areolar   tissue.     Lining   the 


ANATOMY    AND    PflVSn )!.()(;  V  147 

surface  of  the  mucous  membrane  is  a  single  layer  of 
columnar  epithelium  ;  and  located  in  the  membrane  are  the 
secretory  glands  of  the  stomach.  These  latter  are  of  two 
kinds.  One  kind  is  situated  mostly  at  the  pyloric  end,  and 
consist  of  glands  lined  throughout  by  an  extension  of  the 
surface  columnar  epithelium.  The  other  kind,  the  so-called 
'  peptic  glands,'  are  lined  with  columnar  epithelium  near  the 
surface,  but  towards  their  deeper  parts  the  cells  assume  more 
of  a  spheroidal  character.  The  mucous  membrane  is  thinnest 
in  the  large  cul-de  sac  and  thickest  in  the  pyloric  region. 
It  moves  freely  on  the  muscular  layer  owing  to  the  looseness 
of  the  intervening  submucous  areolar  tissue.  Hence,  when 
in  a  contracted  condition,  it  assumes  numerous  folds,  which 
become  obliterated  on  distension  of  the  organ. 

The  stomach  receives  its  arterial  supply  from  the  three 
branches  of  the  coeliac  axis  ;  the  greater  cul-de-sac  and 
cardiac  region  being  supplied  from  the  splenic  and  gastric 
branches,  and  the  pyloric  region  from  the  hepatic.  The  main 
trunks  pass  round  the  greater  and  leseer  curvatures  between 
the  layers  of  the  two  omenta,  and  from  them  branches 
ramify  through  the  coats  of  the  stomach,  finally  ending 
in  a  dense  capillary  network  around  the  secreting  tubules. 
The  veins  which  arise  from  this  network  eventually  empty 
into  the  splenic,  superior  mesenteric,  and  portal  veins. 
The  lymphatics,  which  form  a  dense  network  in  the  mucous 
membrane,  surrounding  alike  the  glands  and  the  blood 
vessels,  end  by  traversing  the  lymphatic  glands  which  exist 
along  both  curvatures  of  the  stomach.  The  nerve  supply  is 
from  the  cerebro- spinal  and  sympathetic  systems.  In  the 
former  it  is  through  the  pneumogastrics,  the  left  being 
distributed  to  the  anterior  surface,  and  the  right  to  the 
posterior  ;  in  the  latter  it  is  through  the  solar  plexus.  In 
addition  there  are  plexuses  of  nerves  and  ganglia  contained 
within  the  visceral  walls. 

Physiology. — The  functions  of  the  stomach  are  twofold — 
(1)  digestion,  (2)  motion. 

The  digestive  properties  consist  in  the  conversion  of 
nitrogenous  or  albuminous  food  into  chyme  ;  oleaginous  and 
starchy  materials  being  uninfluenced.  This  action  is  efiected 
conjointly  by  a    ferment  called  pepsin  and  by  hydrochloric 


148  THE   STOMACH 

acid ;  these  agents,  together  with  some  chlorides  and 
phosphates  and  a  large  proportion  of  water,  constitute  the 
gastric  juice. 

The  movements  of  the  stomach,  brought  about  by  the 
contraction  of  its  muscular  coat,  entail  in  the  first  place  a 
thorough  mixing  of  the  ingested  material  with  the  gastric 
secretion ;  and  in  the  second  its  propulsion  from  the  stomach 
into  the  duodenum.  The  food  as  it  enters  the  stomach 
passes  through  the  relaxed  or  dilated  cardiac  orifice  ;  it  is 
then  compressed  by  the  contraction  of  the  gastric  parietes, 
and  prevented  from  passing  into  the  duodenum  by  closure 
of  the  pyloric  sphincter,  and  from  regurgitation  into  the 
oesophagus  by  recontraction  of  the  cardiac  orifice.  The 
peristaltic  action  which  sets  in,  besides  serving  more  effici- 
ently to  aid  digestion,  causes,  according  to  Brinton,  a  peculiar 
circulation  of  the  contents  of  the  stomach,  whereby  the 
digested  materials  take  a  peripheral  course,  and  are  finally 
propelled  through  the  relaxed  pyloric  orifice  into  the  duo- 
denum. The  central  undigested  portions,  if  not  capable  of 
digestion,  follow  as  the  residual  products,  the  pyloric 
si^hincter  dilating  sufficiently  to  admit  of  their  passage. 

Various  circumstances  affect  the  normal  process  of 
digestion.  In  some  instances  these  are  connected  with 
certain  physical  causes,  in  others  they  are  dependent  upon 
the  nature  of  the  food  taken,  and  a  third  class  are  associated 
with  various  nerve  influences.  Digestion  is  impeded  when 
the  temperature  of  the  contents  of  the  stomach  rises  a  few 
degrees  above  100°  F.,  or  sinks  a  few  below  it.  Thus  the 
ingestion  of  too  much  ice  or  a  large  quantity  of  cold  water 
is  liable  to  retard  the  action  of  the  gastric  juice.  Again, 
any  lack  in  the  proper  movements  of  the  stomach,  whereby 
its  contents  fail  to  become  well  mixed  with  the  gastric 
secretion,  hinders  digestion  ;  and,  lastly,  any  hindrance  to  a 
proper  removal  of  the  already  digested  material,  such  as 
arises  in  cases  of  pyloric  obstruction,  tends  to  a  hke 
detrimental  result.  With  regard  to  the  nature  of  the  foods 
taken,  certain  substances  appear  to  be  more  easily  or  more 
rapidly  digested  than  others.  Thus,  as  the  result  of  some  of 
Beaumont's  '  researches,  it  would  seem  that  the  flesh  of  wild 

'  Princixiles  of  Uuman  Fhysiologij,  Carpenter,  7th  edit.  p.  134. 


METHODS   OF   EXAMINATION  149 

animals  is  more  easily  digested  than  that  of  those  of  a  more 
domesticated  kind.  And,  further,  that  of  these  latter,  beef  is 
more  digestible  than  mutton,  and  mutton  than  either  veal  or 
pork.  Fowls  are  not  so  digestible  as  turkey ;  this  latter,  with 
the  exception  of  venison,  being  one  of  the  most  digestible  of 
animal  foods.  The  time  taken  for  the  complete  digestion  of  a 
meal  varies  between  three  and  four  hours.  Among  other  cir- 
cumstances which  may  be  said  to  affect  the  process  of  gastric 
digestion  are  the  general  state  of  bodily  health,  the  state  of 
the  mind,  the  amount  of  exercise  before  and  after  a  meal,  the 
time  since  the  last  meal,  and  the  quantity  and  quality  of  the 
food  taken. 


CHAPTER   XVIII 

METHODS,    (1)    OF    OBTAINING    GASTRIC     JUICE    FOR    EXAMINATION. 

(2)  FOR    DETECTION    OF    FREE    HYDROCHLORIC    ACID. 

(3)  OF  ASCERTAINING  THE  RATE  OF  GASTRIC  ABSORPTION. 

(4)  FOR     DETERMINING     THE     MOTOR     POWER     0F„    THE 

STOMACH. 
PHYSICAL    EXAMINATION.       PALPATION  ;    PERCUSSION  ; 
AUSCULTATION  ;    INFLATION  ;    GASTROSCOPY  ;    GASTRODIAPHANY 

In  view  of  the  increasing  clinical  importance  of  a  practical 
knowledge  of  the  constituents  of  the  gastric  juice  and  the 
movements  of  the  stomach  in  certain  diseases,  it  would  seem 
advisable  to  describe  these  various  conditions  as  they  are 
supposed  to  exist  in  the  normal  state,  and  the  methods 
adopted  for  ascertaining  them.  In  what  follows,  the  informa- 
tion has  been  mostly  derived  from  Ewald's  'Lectures  on 
Diseases  of  the  Stomach  '  as  translated  by  Saundby.^ 

(1)  Method  of  obtaining  gastric  juice  for  examination. — In 
order  to  obtain  the  gastric  juice  it  is  necessary  in  the  first 
place  to  excite  its  secretion,  and  in  the  second  to  do  so  by 
such  means  as  will  not  materially  alter  the  juice  so  secreted. 
For  this  purpose  what  is  termed  a  '  test  meal '  is  administered. 
As  an  example  of  this  kind  of  meal,  I  shall  only  mention  that 
which  goes  under  the  name  of  '  Ewald's  test  breakfast.'     It 

New  Sydenham  Society,  1892,  vol.  ii.  Lecture  I. 


lAO  THE   STOMACH 

consists  of  an  ordinary  dry  roll  and  about  three-quarters  of  a 
pint  of  warm  water  or  very  weak  tea  taken  upon  an  empty 
stomach. 

At  the  expiration  of  one  hour  the  contents  of  the  stomach 
are  removed  in  the  following  way.  The  stomach  tube — whicli 
should  have  a  terminal  hole  and  lateral  ones,  and  be  made  of 
soft  rubber — should  be  dipped  in  warm  water  and  then  pushed 
gently  backwards  to  the  posterior  wall  of  the  pharynx.  The 
patient  is  then  requested  to  swallow,  and  by  the  additional 
exercise  of  slight  propulsion  on  the  part  of  the  operator,  the 
tube  can  easily  and  quickly  be  introduced.  The  tube  thus 
within  the  stomach,  its  contents  may  be  extracted  in  one  or 
more  ways,  either  by  suction  with  a  pump,  by  the  use  of  a 
compressed  elastic  ball,  which  on  expansion  sucks  up  the 
material  into  it,  or  by  a  simple  process  described  by  Ewald 
and  known  as  his  '  method  of  expression.'  This  last  consists 
either  in  abdominal  pressure  exercised  by  the  operator,  or  in 
active  expressure  on  the  part  of  the  patient ;  both  methods 
push  the  contents  of  the  stomach  into  the  tube,  provided  only 
that  .the  former  are  sufficiently  fluid.  As  pointed  out  by 
Ewald,  this  method  should  not  be  tried  when  there  is  danger 
of  rupture  of  an  aneurysm,  brittle  vessels,  &c. ;  and,  again,  it 
may  fail  '  when  the  abdominal  wall  is  so  relaxed  that 
abdominal  pressure  cannot  be  applied,  and  where  the  patient 
has  no  control  over  his  muscles,  and  is  unable  to  press 
when  desired  to  do  so,  or  perhaps  make  convulsive  efforts  to 
cough.' 

Einhorn  '  has  introduced  an  apparatus  which  '  consists  of 
a  small  oval  vessel  (If  ctm.  long,  |  ctm.  wide)  made  of  silver  ; 
on  the  top  of  the  same  is  a  large  opening  with  an  arch  over  it ; 
on  to  this  arch  a  silk  thread  is  tied.'  The  patient  is  made  to 
swallow  the  '  bucket '  about  an  hour  after  the  test  breakfast. 
After  an  interval  of  five  minutes  it  is  withdrawn,  and  its  con- 
tents can  then  be  tested. 

The  contents  of  the  stomach  thus  removed  are  filtered, 
when  a  fluid  clear  as  water,  but  possibly  tinged  slightly  yellow 
or  brown,  is  obtained  as  a  filtrate.  This  fluid  is  strongly  acid, 
and  owes  its  acidity  to  hydrochloric  acid  and  acid  salts. 

'  Isew  York  Medical  Record,  1890,  vol.  xxxviii.  p.  63. 


METHODS   OF   EXAMINATION  l.-,l 

(2)  Method  jor  ilie  detection    of  free   JiydrocJdoric    acid.— 
Giinzburg's  method. — The  te&t  solution  consists  of 

2  grms.  phloroglucin 
1  grm.  vanillin 
30  grms.  absolute  alcohol. 

'  It  is  not  necessary  to  filter  the  stomach  contents  before 
testing  it.  One  or  two  drops  in  a  capsule  or  on  a  strip  of 
filter  paper  with  the  same  quantity  of  the  reagent  are  suffi- 
cient. .  .  .  The  reaction  is  always  bright  red,  or,  with  very 
small  quantities,  pale  rose  colour.  The  fluid  does  not  change 
on  the  instant  of  adding  it ;  but  if  the  capsule  is  gently  heated 
over  a  lamp,  so  that  the  fluid  does  not  boil  but  slowly 
evaporates,  at  the  border  of  the  evaporated  drops  a  bright 
red  patch  or  small  very  fine  red  streaks  appear.'  Any  excess 
of  heat  causes  a  brown,  brownish-yellow,  or  brownish-red  colour 
to  appear.  This  same  method  for  the  detection  of  hydro- 
chloric acid  may  be  used  for  obtaining  an  approximate  quan- 
titative estimate  of  the  amount  present.  'By  successive 
dilutions  of  stomach  contents  giving  Giinzburg's  reaction  to 
3'  Tf  tVj  <^c.,  until  the  reaction  no  longer  occurs,  we  can 
estimate  approximately  the  amount  of  actually  free  hydro- 
chloric acid,  as  the  lowest  limit  is  about  ^V  P®^  mille.  If  the 
red  colour,  for  example,  is  still  obtained  with  the  twentieth 
dilution,  the  gastric  juice  contains  1*0  per  mille,  or  0"1  per 
cent,  of  free  hydrochloric  acid.  But  one  may  make  a  rough 
guess  at  the  amount  of  acid  according  to  the  intensity  of  the 
red  coloration.' 

(3)  Method  of  determinifig  the  rate  of  absorption  from  the 
stomach. — '  The  absorption  by  the  gastric  mucous  membrane 
is  proved  by  means  of  iodide  of  potassium.  Following 
Penzold  '  we  give  small  doses,  0-1  grm.,  in  capsules  which  are 
carefully  wiped  so  that  no  iodide  of  potassium  is  on  the  out- 
side, a.nd  we  determine  the  moment  when  the  salt  first  appears 
in  the  saliva,  by  help  of  its  well-known  reaction  on  starch 
solution.  Filter  paper  is  soaked  in  starch  solution,  dried,  and, 
after  the  capsule  has  been  taken,  the  saliva  of  the  patient  is 
tested  with  it  from  time  to  time,  about  every  five  minutes. 

'  Penzold  and  Faber,   '  Resorptionsfahigkeit   des   menschlichen    Magens,' 
Berliner  klin.  Wochenschrift  1882.  No.  21,  p.  31S. 


152  THE   STOMACH 

On  the  addition  of  fuming  nitric  acid  we  can  recognise  at  once, 
by  the  occurrence  of  the  blue  colour,  the  appearance  of  iodine 
in  the  saliva.  As  a  rule  it  takes  place  in  about  ten  to  fifteen 
minutes.  But  when  absorption  from  the  stomach  is  delayed, 
the  reaction  may  appear  much  later,  from  half  an  hour  to  an 
hour  or  more.  .  .  .  When  absorption  is  delayed  until  one  or  one 
and  a  half  hour  after  eating,  it  is  distinctly  pathological.' 

(4)  Method  for  determining  the  motor  2^0 wer  of  the  stomach. 
The  object  of  this  investigation  is  to  ascertain  the  rapidity 
with  which  substances  taken  into  the  stomach  are  transmitted 
by  it  into  the  duodenum.  This  has  been  approximately 
effected  by  the  administration  of  salol,  a  substance  which  is 
not  acted  upon  by  the  gastric  juices,  but  becomes  decomposed 
when  under  the  influence  of  the  pancreatic  secretion.  Salol 
splits  up  into  salicylic  acid,  phenol,  and  the  conversion  product 
of  salicylic  acid,  salicyluric  acid.  '  Under  normal  conditions, 
salicyluric  acid  appears  in  the  urine  forty  to  sixty  or  at  latest 
seventy-five  minutes  after  one  gramme  of  salol  has  been  taken, 
which  is  best  given  during  digestion — longer  delay  indicates 
slowing  of  the  transfer  into  the  intestine.  Salol  is  a  tasteless 
white  powder,  and  is  easily  taken.  It  may  be  ordered  in  cap- 
sules, or  employed  in  the  form  of  keratin  pills,  but  sometimes 
these  pass  undissolved  through  the  bowel,  and  such  pills  may 
easily  remain  for  varying  and  abnormal  lengths  of  time 
entangled  in  folds  of  the  gastric  mucous  membrane.  The  advan- 
tage of  salol  is  that  it  mixes  intimately  with  the  stomach 
contents,  and  certainly  accompanies  its  general  movements. 
Salicyluric  acid  is  easily  recognised  in  the  urine  on  the  addition 
of  neutral  ferric  chloride  solution,  which  produces  a  violet 
colour.  To  detect  the  first  traces,  the  urine  is  acidulated  with 
hydrochloric  acid  and  shaken  with  ether ;  the  salicyluric  acid 
is  taken  up  by  the  ether  and  can  easily  be  detected  in  the  ether 
residue.  More  simple  and  no  less  certain  is  the  plan  of  dipping 
apiece  of  filter  paper  into  the  urine  and  then  letting  a  drop  of 
ferric  chloride  fall  on  it.  The  edge  of  the  drop  becomes  violet 
in  the  presence  of  the  merest  trace  of  salicyluric  acid.'  In 
addition  to  the  time  at  which  the  acid  first  appears  in  the 
urine,  after  administration  of  the  salol,  there  is  also  the  time 
during  which  it  lasts.  In  healthy  persons  its  excretion  continues 
for  twenty-four  hours,  while  in  patients  with  some  impairment 


niVSICAL   EXAMINvVTION  153 

of  the  motor  function  of  the  stomach  this  may  be  protracted 
for  forty-eight  hours  or  longer. 

In  giving  the  above  methods  I  have  merely  selected  those 
which  seemed  simplest,  surest,  and  sufficient  for  the  more 
limited  demands  of  a  work  whose  chief  aim  is  to  deal  with 
the  surgical  aspects  of  the  subject.  The  reader  therefore  is 
referred  to  the  first  of  Ewald's  Lectures,  from  which  the  above 
abstracts  have  been  taken,  for  a  more  detailed  description  of 
the  methods  here  briefly  given  :  for  a  fuller  criticism  of  such 
discrepancies  as  may  arise  in  connection  with  them  ;  and  for 
an  account  of  various  methods  for  the  detection  and  analysis 
of  the  other  constituents  of  gastric  juice  and  gastric  digestion. 

Physical  examination. — There  remain  certain  other  means 
for  ascertaining  the  state  of  the  stomach — the  so-called  physical 
methods  of  examination.  These  are  :  palpation,  percussion, 
auscultation,  inflation,  gastroscopy,  and  gastrodiaphany. 

Palpation. — To  examine  the  stomach  through  the  parietes 
by  means  of  the  hand,  considerable  care  is  required  to  avoid 
throwing  the  abdominal  muscles  and  particularly  the  recti 
into  contraction.  If  the  tips  of  the  fingers  are  used,  or  if  the 
hand  be  applied  cold,  a  reflex  spasm  of  the  muscles  is  almost 
certain  to  be  induced. 

The  patient,  lying  in  the  recumbent  position,  with  the 
knees  drawn  up  and  the  chest  raised,  should  be  enjoined  to 
voluntarily  resist  any  contraction  of  the  abdominal  muscles. 
The  palm  of  the  hand  and  the  entire  palmar  aspect  of  the 
fingers,  previously  warmed  if  necessary,  should  be  placed  flat 
on  the  abdomen.  Then  by  a  rotatory  movement  of  the  hand, 
coupled  with  gentle  and  gradual  pressure  exercised  by  the 
flexor  surfaces  of  the  terminal  phalanges,  both  a  superficial 
and  deep  examination  can  be  made.  In  certain  cases  further 
information  may  be  gained  by  palpating  in  the  knee  elbow 
position.  In  all  cases  palpation  is  more  efficiently  carried  out 
when  the  patient  is  under  an  ana3sthetic.  Vigorous  palpation 
will  elicit  sounds  of  splashing  when  conditions  exist  favourable 
for  its  production. 

Percussion. — As  a  method  of  examination  percussion,  as 
ordinarily  practised,  is  of  little  diagnostic  value.  A  tympanitic 
note  may  be  heard,  but  in  cases  where  the  colon  overlaps 
or  is  situated  just  below  the  stomach,  it  is  not  possible  to 


154  THE    STOMACH 

distinguish  where  the  one  ends  and  the  other  begins.  In  a 
paper  by  E.  A.  Fleming '  an  attempt  is  made  to  show  that 
by  the  combined  methods  of  auscultation  and  percussion  it 
is  possible  to  delineate  with  a  considerable  degree  of  accuracy 
the  lower  boundary  of  the  stomach.  The  stethoscope  is  applied 
to  the  stomach  *  in  what  has  been  called  Traube's  area,  i.e.  to 
the  left  of  the  mid-abdominal  line  and  between  the  free  edge 
of  the  left  lobe  of  the  liver  and  the  costal  margin — where,  in 
most  cases,  the  stomach  is  in  direct  contact  with  the  abdominal 
wall.  But  if  some  suspicion  exists  as  to  whether  colon  or 
stomach  underlies  this  area,  the  stethoscope  may  be  placed 
between  the  left  border  of  the  xiphoid  cartilage  and  the  costal 
margin.  This  of  necessity  means  auscultating  through  the 
thin  edge  of  the  left  lobe  of  the  liver,  but,  notwithstanding, 
the  sound  produced  by  the  percussing  finger  is  very  clearly 
conveyed  to  the  ear.  ...  In  all  the  cases  tested,  I  used  both 
the  finger  and  also  an  ivory  pleximeter  and  percussed  with 
one  finger.  A  note,  probably  stomach,  was  obtained  by  per- 
cussing close  to  the  stethoscope ;  and  then  by  commencing  (on 
the  left  side  of  the  abdomen)  below  the  umbilicus,  or,  in  cases 
of  suspected  dilatation,  as  low  as  the  symphysis,  the  stomach 
note  could  be  at  once  detected  by  the  auscultating  ear  when- 
ever the  stroke  was  made  over  it,  even  though  the  colon  over- 
lapped. Great  care  was  taken  to  percuss  vertically  down- 
wards, and  the  patient  was  always  in  the  recumbent  posture.' 

Auscultation. — Apart  from  its  use  in  conjunction  with  per- 
cussion, auscultation  is  of  little  value  as  a  diagnostic  means. 
Unlike  the  oesophagus,  there  is  no  constant  or  typical  sound 
produced  by  movements  of  the  contents  of  the  stomach,  and 
such  sound  as  has  been  noted — that  is,  that  produced  by  the 
passage  of  food  through  the  cardiac  orifice  into  the  stomach — 
is  both  uncertain  and  wanting  in  constancy  of  character.  In 
cases,  however,  of  serious  obstruction  at  the  cardiac  orifice, 
there  will  be  complete  absence  of  any  sound. 

Inflation  or  Distension. — In  cases  where  it  is  necessary  to 
ascertain  the  size  and  position  of  the  stomach,  the  viscus  is 
inflated  with  gas.  There  are  different  ways  of  doing  this. 
One  of  the  simplest  is  to  insert  the  stomach  tube,  attach  to 
its  free  end  the  bellows  of  an  ordinary  spray  apparatus,  and 

'  Edinburgh  Hospital  Reports,  1893,  vol.  i.  p.  69. 


rilYSiCAL   EXAMINATION  15o 

then  pump  in  air.  When  the  patient,  or  the  stomach,  can 
no  longer  endure  any  increase  in  the  distension,  the  air  will 
escape  by  the  side  of  the  tube,  and  this  it  will  usually  do  more 
readily  than  pass  into  the  duodenum.  The  meLhod  of  infla- 
tion alone  does  not,  however,  entirely  get  over  the  difficulty 
of  distinguishing  a  dilated  stomach  filled  with  air,  from  the 
transverse  colon  distended  with  gas.  The  following  method, 
adojited  by  Dehio  and  recommended  by  Ewald,'  appears  to 
obviate  this  difficulty.  '  The  patient  must  drink  at  intervals 
four  quarter-litres  of  water,  so  that  he  takes  a  whole  litre  in 
four  portions.  If  after  each  quarter-litre  has  been  taken  the 
limits  between  the  lower  semicircular  dulness  and  the  dis- 
tended transverse  colon  be  clearly  ascertained  by  means  of 
percussion,  these  limits  in  a  healthy  patient,  when  he  is  in  a 
standing  position,  may  be  seen,  in  proportion  to  the  fluid 
poured  into  the  stomach,  to  advance  downwards  to  about  a 
few  centimetres  above  the  umbilicus,  but  never  below  it. 
When  the  patient  is  lying  down,  tympanitic  resonance,  caused 
by  the  air  which  is  swallowed  at  the  same  time  as  the  water, 
takes  the  place  of  the  dulness,  and  this  prompt  change  of  sound 
is  a  certain  proof  that  it  is  the  stomach  and  not  the  bowel.' 

In  marked  cases  of  dilatation  following  upon  obstruction 
at  the  pylorus,  it  is  sometimes  sufficient  to  pour  in  through  a 
stomach  tube  some  pints  of  warm  water.  The  extreme  emacia- 
tion which  usually  accompanies  these  conditions  admits  of 
the  distension  of  the  stomach,  and  the  descent  of  its  greater 
curvature  being  visibly  observed  and  easily  determined  by 
palpation. 

Gastroscopy. — With  regard  to  this  method  of  investigation, 
all  that  can  be  said  is  that  it  has  been  attempted.  Leiter  has 
constructed  a  gastroscope,  and  Mikulicz  ^  has  employed  it  with 
some  measure  of  success. 

Gastrodiaphany. — Like  the  above,  this  method  of  examina- 
tion has  received  up  to  the  present  but  a  very  limited  trial.  Its 
use  has,  however,  been  attended  with  success,  and  Solis-Cohen  ^ 
speaks  of  having  used  the  gastrodiaphane  '  with  satisfaction.' 

'  Lectures  on  Diseases  of  the  Stomach,  vol.  ii.,  New  Sydenham  Society, 
1892. 

*  Wiener  med.  Wochenschrift,  1883,  vol.  xxxiii.  p.  748. 

'  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  i.  C— 9. 


156  THE    STOMACH 

This  author  thus  describes  Einhorn's  method  of  translumina- 
tion  or  gastrodiaphany  :  '  The  patient,  fasting,  drinks  one  or  two 
glassfuls  of  water,  and  the  apparatus  (consisting  of  an  electric 
lamp,  attached  to  a  soft-rubber  tube  containing  the  connecting 
wires),  lubricated  with  glycerine, is  then  inserted  (or  rather  swal- 
lowed). In  a  dark  room,  the  patient  being  either  in  a  standing 
or  lying  position,  a  reddish  luminous  zone  upon  the  abdomen 
indicates  the  outline  and  position  of  the  stomach.  Thickening 
of  the  anterior  wall,  as  by  neoplasm,  obscures  or  prevents  the 
illumination.  The  method  is  especially  valuable  in  delimiting 
the  lesser  curvature  in  gastrectasia  and  gastroptosis.  Hering 
and  Eeichmann's  lamp,  described  by  Eenvers  and  Pariser  at 
the  Berlin  Medical  Society,  appears  to  be  larger  than  that  of 
Einhorn,  and  is  covered  by  a  small  glass  vase  filled  with  water. 
They  wash  out  the  stomach  and  introduce  one  and  a  half  to 
two  litres  of  water  before  inserting  the  lamp.  The  patient 
must  be '  standing,  as  the  full  stomach  falls  away  from  the 
abdominal  wall.  A  case  of  carcinoma  was  thus  diagnosticated 
and  confirmed  by  section.  The  tumour  appeared  as  a  dark 
spot  in  a  light  field.' 


CHAPTER   XIX 


INJURIES  :  CONTUSION,  TRAUMATIC  RUPTURE,  TRAUMATIC 
PERFORATION,  GUNSHOT  WOUND 

Contusions. — Cases  of  uncomplicated  contusions  of  the 
stomach  are  rare.  It  is  more  usual  for  the  injury  which 
produces  the  contusion  to  inflict  at  the  same  time  some  graver 
lesion  elsewhere,  with  the  result  that  the  symptoms  which 
might  be  sufficient  to  indicate  the  stomach  mischief  are  m^ore 
than  obscured  by  the  severity  of  those  arising  from  the  damage 
to  other  parts. 

When  the  injury  to  the  stomach  wall  has  been  sufficiently 
severe,  some  after  effects  may  result.  Thus  either  an  acute 
or  chronic  inflammatory  23rocess  may  be  set  up,  the  patient 
suffering  from  symptoms  of  an  acute  or  chronic  gastritis. 
"While  the  symptoms  of  these  affections  will  be  best  learnt  by  a 
reference  to  the  same  conditions  as  they  arise  from  other  causes 


CONTUSIONS   AND   IIUPTUKE  ir,7 

and  are  fully  described  in  books  on  medicine,  the  surg;eon  should 
be  familiar  with  a  few  of  the  more  prominent  manifestations. 
In  acute  gastritis  there  is  pain  in  the  epigastrium,  frequently 
of  an  intermittent  character  and  augmented  by  the  ingestion 
of  food.  Pressure  with  the  hand  in  the  left  hypochondrium 
may  cause  a  feeling  of  tenderness  ;  and  deep  inspiration  may 
also  cause  distress  from  pressure  of  the  diaphragm  downwards. 
Various  febrile  disturbances  may  be  present,  such  as  rise  of 
temperature,  rapid  pulse,  thirst,  scanty  urine,  nausea,  and 
constipation. 

When  the  inflammation  assumes  a  more  chronic  character, 
dyspeptic  symptoms  will  arise.  In  two  cases  quoted  by 
Poland  '  an  abscess  formed  which  subsequently  burst  and  gave 
rise  to  a  fistula. 

It  must  be  remembered  that  it  is  not  always  easy  to 
distinguish  between  symptoms  arising  from  inflammation  of 
the  peritoneum  and  those  due  to  a  like  condition  of  the 
stomach. 

Treatment.— At  whatever  stage  of  the  affection,  whether 
early — that  is,  shortly  after  the  accident — or  later  when  inflam- 
matory mischief  has  become  manifest,  rest  must  be  procured 
for  the  injured  or  diseased  organ.  Strength  must  be  sustained 
as  much  as  possible  by  the  administration  of  nutrient  enemata  ; 
and  when  it  is  found  necessary  to  give  food  by  the  mouth, 
this  should  be  of  a  kind  to  entail  as  little  functional  activity 
of  the  organ  as  possible.  The  foods  chosen  should  be  easily 
digestible,  non-irritant,  nutritious,  and  given  in  small  quanti- 
ties frequently. 

Ruptures. — It  is  possible  that  as  an  accident  contusion  is 
more  frequent  than  rupture,  although,  post  mortem,  ruptures 
are  certainly  more  often  seen.  Like  contusions,  however, 
the  injury  is  very  frequently  associated  with  graver  lesions. 
In  the  only  case  which  I  have  seen,  that  of  a  boy  admitted 
under  my  care  in  the  Victoria  Infirmary,  the  spleen  was 
also  ruptured.  In  four  cases  recorded  separately  by  Poland.^ 
Erichsen,^    Pollock,'*   and   Clayton,'^    a   similar   complication 

'  Guifs  Hospital  Reports,  3rcl  series,  vol.  iv.  p.  132.  -  Ibid. 

3  Science  and  Art  of  Surgery,  9th  edit.  vol.  i.  p.  877. 
''  Holmes's  System  of  Surgery,  3rd  edit.  vol.  i.  p.  876. 
5  Brit.  Med.  Journ.  189-1,  vol.  i.  p.  684. 


158  THE   STOMACH 

existed.  The  liver  is  not  infrequently  injured.  In  a  case 
reported  by  Morris/  the  left  lobe  was  displaced  into  the 
left  pleural  cavity,  through  a  rent  in  the  diaphragm.  In 
Poland's  case  also,  the  liver  was  involved.  In  a  table  of 
eleven  cases  collected  by  Grant  Andrew,^  reference  is  made 
to  a  case  of  Buist's  where  the  spleen  was  ruptured ;  and 
to  one  by  Andrew  Wilson  where  the  liver  was  similarly 
involved.  When  the  close  anatomical  relations  of  these  two 
organs,  the  liver  and  the  spleen,  to  the  stomach  is  remem- 
bered, it  will  be  evident  that  in  all  severe  ruptures  one  or 
the  other  or  both  of  these  viscera  may  be  implicated. 
Minor  ^  records  a  case  where,  in  addition  to  a  rupture  of  the 
stomach  which  involved  the  lesser  curvature  and  extended  in 
the  long  axis  of  the  organ,  a  rupture  of  the  ileum  was  also 
found. 

The  nature  of  the  rupture  varies.  In  some  cases  only  the 
peritoneal  coat  is  severed,  in  others  only  the  mucous,  while 
in  all  cases  of  any  severity  the  entire  wall  is  divided.  The 
lesion  may  be  located  in  any  part  and  may  be  of  any  extent, 
and,  further,  there  may  be  more  than  one  lesion.  In  the 
case  reported  by  Clayton,  '  the  mucous  membrane  was  seen 
to  be  raptured  in  two  places,  the  one  being  on  the  anterior 
surface  midway  between  the  cardiac  and  pyloric  extremities, 
of  a  somewhat  irregular  star-shaped  area  one  inch  in 
diameter,  the  mucous  membrane  alone  being  stripped  from 
the  underlying  muscular  coat ;  the  other  was  situated  on 
the  posterior  wall  immediately  opposite  to  the  one  on  the 
anterior  wall,  and  resembling  it  in  size  and  in  its  limitation 
to  the  mucous  coat.'  In  some  very  severe  instances  the  organ 
has  been  torn  completely  through.  In  such  cases  the  injuries 
appear  to  involve  most  frequently  the  pyloric  region.  The 
extent  of  the  lesion  is  largely  determined  by  the  amount  of 
distension  at  the  time  of  the  injury. 

Traumatic  ruptures  result  either  from  a  severe  blow  in 
the  epigastric  and  left  hypochondriac  regions,  or,  as  is  more 
frequently  the  case,  from  a  tight  squeeze ;  or  from  a  crush 


'  International  EncyclopcBdia  of  Surgery,  vol.  v.  p.  8G9. 
2  Trans.  Path,  and  Clin.  Soc.  Glasgotv,  1895,  vol.  v.  p.  38. 
^  Nno  Ycrk  Med.  Junrn.  1887,  p.  3G0. 


RUPTURE  159 

such  as  is  produced  by  the  passage  of  a  wheel  of  a  heavy 
vehicle  over  the  body. 

Symptoms, — An  injury  sufficiently  severe  to  cause  a  com- 
plete rupture  of  the  stomach  gives  rise  to  symptoms  of  more 
or  less  j)rofound  collapse.  Great  pain  is  complained  of  in  the 
upper  part  of  the  abdomen,  coupled  with  vomiting  in  which 
the  ejecta  ma}'  or  may  not  contain  blood.  If  death  does 
not  ensue  shortly  after  the  accident,  some  temporary  rallying 
may  take  place  ;  but  the  patient,  after  a  variable  period  of 
restlessness  and  great  suffering,  sinks  again  into  a  state  of 
collapse  terminating  in  death. 

In  the  less  severe  forms  of  injury,  where  the  rent  may  only 
have  involved  the  serous  or  mucous  coat,  or  the  complete 
rupture  has  been  too  slight  to  admit  of  any  escape  of  the 
gastric  contents,  the  symptoms  will  be  less  marked.  The 
primary  collapse  may  be  comparatively  slight,  and  the  patient, 
when  once  well  out  of  the  immediate  shock,  may  make  an  unin- 
terrupted recovery.  It  is,  however,  in  these  milder  forms  of 
injury  that  secondary  and  later  complications  may  sometimes 
arise.  Thus,  in  a  case  recorded  by  Limont  and  Page,*  cicatricial 
contraction  resulted  in  the  region  of  the  pylorus  after  a  blow 
received  seventeen  years  previously.  In  other  instances  an 
abscess  may  form  at  the  seat  of  lesion  and,  bursting  externally, 
give  rise  to  a  gastric  fistula.  Coutaret  ^  describes  a  condition 
which  he  terms  '  entasis,'  and  which  is  due  to  the  '  partial 
rupture  or  detachment  of  the  peritoneum,  or  of  the  attachment 
of  the  stomach,  spleen,  pancreas,  or  liver  with  a  circumscribed 
exudative  peritonitis  which  may  eventuate  in  recovery  or 
in  an  abscess  which  opens  externally  or  into  a  viscus.  .  .  . 
Digestion  is  impaired  slowly,  and  emaciation  is  usually  in- 
sensible. The  characteristic  sign  is  impossibility  of  sustained 
physical  exertion.'  If  no  abscess  or  other  untoward  symptom 
shows  itself,  recovery  may  be  expected  in  from  six  to  eighteen 
months. 

Treatment. — The  profound  shock  which  usually  exists  in 
severe  cases,  renders  out  of  the  question  all  considera- 
tions other  than  those  directed  to  the  patient's  collapsed 
condition.     However  strong  may  be  the  evidences  of  rupture 

'  Lancet,  1892,  vol.  ii.  p.  84 ;  also  Brit.  Med.  Journ.  1893,  vol.  ii.  p.  427. 
-  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  i.  C — 9. 


IGO  THE   STOMACH 

of  the  stomach,  it  would  only  be  cutting  the  last  thread  of 
life  to  venture  upon  anything  operative  at  this  critical  period. 
Every  endeavour  should  therefore  be  made  to  rally  the 
patient.  Warmth  should  be  freely  applied  all  over  the  body, 
and  warm  brandy  enemata  administered.  So  soon  as  there 
is  distinct  indication  oi  the  patient's  strength  increasing,  as 
shown  by  a  better  pulse,  there  is  nothing  but  harm  to  be 
gained  by  delaying  an  operation.  The  cases  are  by  far  too  few 
and  too  varying  to  admit  of  any  definite  statement  being  made 
as  to  what  should  be  done,  we  only  know  that  in  a  bad  case  of 
rupture  death  will  certainly,  in  most  if  not  in  all  instances, 
ensue ;  while  we  equally  know  that  to  open  the  abdominal 
cavity,  properly  cleanse  it,  and  stitch  up  any  rent  discoverable 
in  the  gastric  wall,  is  neither  a  grave  nor  a  long  operation,  and 
one  which  follows  the  same  lines  in  which  ruptures  in  other 
parts  of  the  alimentary  canal  have  been  successfully  treated. 
But  for  the  frequency  of  severe  injury  to  other  parts,  there  is 
no  reason  why  an  early  operation,  performed  as  above  in- 
dicated, should  not  prove  as  successful  in  rupture  from  accident 
as  in  perforation  from  disease.  Before  the  administration  of 
the  ana3sthetic  a  hypodermic  of  morphia  should  be  given  to 
prevent  further  shock. 

As  regards  later  complications,  Limont's  case  of  cicatricial 
contraction  of  the  pylorus  was  successfully  treated  by  pylo- 
roplasty. Page  exhibited  the  patient  at  the  annual  meeting 
of  the  British  Medical  Association,  at  Newcastle,  in  1893.  He 
was  then,  seventeen  months  after  the  operation,  perfectly  well 
and  at  work.  The  treatment  of  a  gastric  fistula  will  largely 
depend  upon  its  size  and  the  physical  inconvenience  to  which 
it  gives  rise.  When  the  orifice  is  small  it  may  be  possible  to 
occlude  it  by  a  plastic  operation.  Pollock '  quotes  a  case  by 
Mipdeldorpf  in  which  the  latter  operated  by  bringing  up  a 
flap  of  skin  from  the  lower  extremity  of  the  opening,  and 
fixing  it  to  the  edges  of  the  orifice  by  sutures.  When,  however, 
such  endeavours  fail  or  are  not  feasible,  some  more  radical 
measure  must  be  adopted.  The  abdomen  should  be  opened 
in  the  region  of  the  fistula,  the  latter  excised,  and  the  stomach 
wound  completely  occluded  by  sutures ;  it  is  then  allowed  to 

'  Holmes's  System  of  Siirgery,  3rd  edit.  vol.  i.  ji.  900. 


PENETRATING    WOUNDS  101 

drop  into  the  abdominal  cavity,  and  tlio  operation  completed 
by  uniting  the  edges  of  the  parietal  wound. 

Case  XLV. — Rupture  of  tJi,e  stomach  and  sjileen.  Death,. 
A  boy  aged  17  was  admitted  into  the  Victoria  Infirmary,  Glasgow, 
under  my  care,  at  10  a.m.  on  December  10,  1892.  He  had  received  a 
severe  squeeze  in  the  upper  part  of  his  abdomen,  being  jammed  between 
the  wall  and  a  cart.  When  admitted,  he  was  in  a  collapsed  condition, 
complaining  of  pain  in  the  lower  part  of  his  abdomen,  and  of  great  diffi- 
culty in  breathing.  He  was  most  distressed  about  his  respiration,  con- 
stantly turning  from  side  to  side  and  crying  out  to  be  relieved.  His  eyes 
had  a  sunken  appearance,  and  his  face  generally  an  ashy-grey,  rather 
pinched  aspect.  His  hands  were  cold  and  somewhat  livid,  and  his  pulse 
small,  feeble,  and  rapid — 132.  Any  manipulation  of  the  abdomen  caused 
pain  and  put  the  muscles  into  rigid  contraction.  There  was  no  abrasion 
nor  bruising  of  the  skin  to  be  seen.  At  6  p.m.  he  was  much  weaker,  his 
pulse  being  very  small  and  hardly  perceptible.  He  craved  to  be  made 
better,  but  seemed  freer  from  pain.  The  abdomen  was  now  quite  flaccid  and 
had  a  livid  appearance.  Manipulation  caused  no  pain,  and  the  impression 
conveyed  was  that  there  was  a  quantity  of  blood  within  the  peritoneal  cavity 
At  6.30  P.M.  extreme  collapse  set  in,  and  he  rapidly  sank.  While  in  the 
infirmary  he  did  not  vomit,  but  it  was  stated  that  he  had  done  so  prior 
to  admission.  It  was  not  ascertained  whether  or  not  the  ejecta  con- 
tained blood.  At  the  post  mortem  the  peritoneal  cavity  was  found  filled 
with  blood.  Both  the  spleen  and  the  stomach  were  found  to  have  been 
ruptured.  (A.  Ernest  Maylard,  '  Clinical  Eeports,'  1892,  Ward  III. 
No.  199.) 

Penetrating  wounds.  — As  the  result  of  a  stab  from  a  knife, 
foil,  or  sword,  the  stomach  may  be  punctured.  The  gravity 
of  the  penetration  depends  upon  the  direction  of  the  wound, 
its  size,  and  the  condition  of  the  stomach  at  the  time. 
Thus  a  small  wound,  or  one  which  is  oblique  in  its  transfixion 
of  the  gastric  wall,  inflicted  upon  an  undistended  organ  will 
be  far  less  severe  than  where  the  opposite  conditions  exist. 
The  contraction  of  the  stomach  wall  is  capable  of  occluding  a 
small  opening,  and  still  more  so  when  it  is  oblique,  so  that 
any  escape  of  material  from  the  stomach  cavity  is  prevented. 
With  the  exception  of  the  escape  of  foods  &c.  into  the 
peritoneal  cavity,  the  only  other  complication  of  any  gravity 
is  haemorrhage,  the  bleeding  sometimes  being  excessively  free 
from  the  wound  in  the  wall  of  the  stomach. 

Symptoms. — The  most  convincing  proof  that  the  stomach 
has  been  penetrated  is  the  escape  of  its  contents  through  the 
external  abdominal  wound.     This,  however,  is  unfortunately 

M 


162  THE   STOMACH 

exceptional,  and  the  diagnosis  has  to  be  often  made  on  much 
less  certain  evidence.  The  position  of  the  external  wound 
and  the  nature  of  the  weapon  producing  the  injury  should 
substantially  assist  in  arriving  at  a  correct  conclusion,  especi- 
ally when  coupled  with  vomiting  and  the  presence  of  blood  in 
the  vomit.  There  is  usually  at  the  outset  considerable  shock, 
combined  with  an  expression  of  great  anxiety,  cold  sweats, 
and  pain  of  an  unremittent  character  radiating  from  the  seat 
of  injury.  At  a  later  stage,  in  cases  of  escape  of  the  gastric 
contents  into  the  peritoneal  cavity,  symptoms  of  acute  peri- 
tonitis will  arise. 

Eepetto '  reports  two  cases  of  stab  wounds.  In  one  the 
patient,  a  man  aged  33,  suffered  from  shock,  and  vomited  food, 
blood,  and  bile.  Laparotomy  was  performed,  and,  after  con- 
siderable search,  a  small  cut  less  than  half  an  inch  was  found 
in  the  stomach  wall.  Eight  Czerny-Lembert  sutures  were 
used,  and  the  man  made  a  good  recovery.  In  the  second  case 
the  patient,  a  man  aged  27  years,  died.  At  the  post  mortem 
both  the  anterior  and  posterior  surfaces  of  the  stomach  were 
found  to  have  been  wounded.  Beck  ^  records  the  case  of  a 
man  aged  17  who  was  stabbed  in  the  upper  and  left  part  of 
the  abdomen.  He  was  shortly  after  seized  with  hiccough  and 
vomiting  of  blood.  After  opening  the  peritoneal  cavity,  a  wound 
in  the  stomach  2-5.  cm.  long  was  found  and  stitched  up. 
The  abdomen  was  washed  out  with  0*6  per  cent,  salt  solution. 
A  good  recovery  ensued. 

Treatment. — What  has  been  already  stated  in  connection 
with  the  treatment  of  cases  of  ruptured  stomach  is  equally 
applicable  here.  The  early  shock  should  be  first  dealt  with, 
and  then,  so  soon  as  the  patient  seems  to  have  regained 
sufficient  strength,  no  delay  should  be  exercised  in  opening  the 
abdomen,  cleansing  its  cavity,  suturing  the  stomach  wound, 
and  reuniting  the  abdominal  incision.  In  those  cases  where 
the  symptoms  are  slight  and  it  is  believed  that  the  wound  is 
small,  the  utmost  rest  should  be  enjoined.  If  nature  is  to 
effect  an  unassisted  cure,  it  will  be  by  adhesion  of  the  wound  to 
neighbouring  parts,  so  that  everything  must  be  done  to  keep  the 
patient  quiet  in  bed,  and  the  stomach  free  from  any  functional 

'   Centralhlatt  fur  Chirurgie,  1893,  No.  38,  p.  832. 
'-'  Brit.  Med.  Juurn.  Epitome,  1894,  vol.  ii.  p.  82. 


GUNSHOT    WOUNDS  163 

activity.  To  relieve  pain  a  hypodermic  of  morphia  may  he 
given,  or  a  few  drops  of  laudanum  may  he  administered  with 
a  nutrient  or  stimulating  enema.  Nothing  should  he  given 
hy  the  mouth  for  at  least  forty-eight  hours  ;  and  if  thirst 
be  very  troublesome  it  will  be  alleviated  by  rectal  injections  of 
warm  water. 

Gunshot  wounds. — It  is  comparatively  rarely  that  this  form 
of  penetrating  wound  comes  under  the  observation  of  the 
civil  surgeon.  The  fact,  however,  that  an  occasional  case 
crops  up  in  our  general  hospitals  renders  it  necessary  to  briefly 
refer  to  the  subject. 

The  nature  of  the  wound,  although  of  a  penetrating 
character,  differs  somewhat  from  those  just  discussed.  A 
bullet  does  not  cause  a  clean-cut  wound,  but  in  its  transit  de- 
stroj's  a  certain  amount  of  tissue.  Hence,  if  it  pass  through 
the  gastric  parietes  into  the  cavity  of  the  stomach,  it  leaves  a 
track  which  is  much  more  liable  to  admit  of  the  escape  of  the 
contents  of  the  stomach  than  in  the  case  of  a  clean  incised 
wound. 

The  symptoms  connected  with  a  gunshot  wound  are  very 
much  like  those  already  described  in  connection  with  a  pene- 
trating one.  The  haemorrhage  from  the  stomach  is  sometimes 
severe,  and  the  blood-stained  condition  of  the  vomit  is  the 
best  evidence  that  that  viscus  or  possibly  the  duodenum  has 
been  penetrated. 

The  danger  of  extravasation  into  the  peritoneal  cavity  is 
so  great  in  this  class  of  wounds,  that  surgeons  are  now  gene- 
rally of  opinion  that  an  exploratory  laparotomy  should  not  be 
delayed.  The  injury,  acr'.ording  to  all  military  records,  is  ex- 
cessively fatal  when  allowed  to  pass  untreated ;  so  that  where 
these  cases  happen  in  civil  practice,  we  should  not  delay  in 
using  the  comparatively  perfect  means  we  have  at  our  dis- 
posal in  our  general  hospitals.  The  wound  in  the  stomach, 
or  perchance  in  the  duodenum,  should  be  carefully  sought 
for,  and  when  found  accurately  sutured.  The  abdominal 
cavity  should  be  thoroughly  cleansed  from  any  foreign  or 
escaped  material  by  freely  flushing  it  with  warm  water  or  a 
warm  solution  of  some  diluted  antiseptic ;  or  if  the  extravasated 
material  be  but  slight,  it  may  be  simply  wiped  away.  As  in 
the  case  of  other  penetrating  wounds,  fistulfe  have  been  known 

M  2 


164  THE   STOMACH 

to  result  from  those  due  to  gunshot  injury.  The  case  of 
Alexis  St.  Martin  is  too  well  known  to  need  anything  further 
than  a  passing  reference.  Whether  or  not  the  question  of 
treatment  arose  in  his  case  it  is  not  possible  to  say.  But  in 
any  case  where  it  may  be  entertained,  the  remarks  above  in 
connection  with  the  treatment  of  penetrating  wounds  will 
equally  apply. 

Case  XLVI. — Pistol-shot   wound  of  the  stomach  :   suture  of  wounds. 

Recovery. 

C.  H.  A.,  aged  18,  was  admitted  on  March  26,  1893,  in  the  Liverpool 
Northern  Hospital.  He  stated  that  while  cleaning  a  pistol  it  suddenly 
went  off.  When  first  seen  he  was  very  restless,  calling  out  with  pain,. and 
asking  for  a  drink  every  few  minutes.  His  lips  were  very  pallid,  his  skin 
covered  with  a  clammy  perspiration,  and  his  pulse  extremely  bad — weak, 
intermitting,  and  irregular.  Breathing  was  shallow,  and  pain  prevented 
his  drawing  a  deep  breath.  The  abdominal  walls  were  rigid,  but  there 
was  no  dulness.  He  vomited  a  quantity  of  blood  before  reaching  the 
hospital.  The  wound  in  the  abdominal  wall  was  a  small  hole  with  black- 
ened edges,  situated  to  the  left  of  the  epigastric  region  and  immediately 
below  the  costal  arch.  Laparotomy  was  performed.  The  wound  of 
entrance  into  the  stomach  was  at  once  seen  on  the  anterior  wall  about 
two  inches  from  the  pylorus  and  midway  between  the  two  borders,  and 
the  wound  of  exit  was  found  on  the  posterior  wall  a  little  nearer  the 
upper  than  the  lower  border.  The  orifices  were  freshened,  and  closed 
by  Lembert's  sutures.  The  bullet  could  not  be  detected  posteriorly. 
The  abdominal  cavity  was  flushed  with  boiled  water.  The  boy  made 
a  rapid  recovery.  The  accident  had  taken  place  when  the  stomach  was 
empty,  the  boy  having  taken  no  solid  food  for  about  six  hours.  (Arthur 
H.  Wilson,  '  Brit.  Med.  Journ.'  1894,  vol.  i.  p.  63.) 

Tiffany  '  records  a  successful  case  of  suture  where  the 
bullet  had  passed  through  the  stomach,  thus  causing  two 
apertures.  The  wound  of  exit  was  under  the  spleen  in  the 
greater  curvature  of  the  stomach. 


CHAPTER   XX 

FOREIGN    BODIES.       GASTROLITHS.      HAIR    CONCRETIONS 

Forei^    bodies. — Solid    substances     incapable    of    being 
digested,  or  only  acted  upon  to  a  limited  extent  by  the  gastric 

'  American  Journal  of  the  Medical  Sciences,  1896,  vol.  cxi.  p.  552. 


FOREIGN   BODIES  165 

juice,  and  of  such  a  size  and  shape  as  to  be  impassable,  or 
passable  only  with  difficulty  through  the  pylorus,  constitute 
what  may  be  broadly  termed  '  foreign  bodies  in  the  stomach.' 
As  a  more  literal  meaning  of  the  term,  the  word  '  foreign  '  also 
implies  substances  in  the  stomach  which  are  abnormal  in 
that  situation. 

As  in  the  case  of  the  cesophagus,  there  is  no  limit  to  the 
list  of  solid  substances  which  may  be  swallowed,  and  con- 
stitute what  are  understood  by  foreign  bodies  in  the  stomach. 
Taken,  however,  as  a  class  of  cases,  they  are  far  less  frequently 
met  with.  They  manifest,  too,  in  their  symptoms,  usually 
much  less  urgency  and  severity ;  and  while  oesophageal  im- 
pactions are  almost  always  associated  with  symptoms  of  some 
kind,  it  not  infrequently  happens  that  a  foreign  body  may 
remain  in  the  stomach  without  causing  anything  but  the 
slightest  gastric  disturbance. 

The  causes  of  a  body  being  detained  are  to  be  found  in 
the  foreign  body  itself,  and  in  the  stomach.  In  the  former 
case  it  is  the  size  of  the  body,  or  its  size  coupled  with  its 
shape  and  consistency  ;  in  the  latter  it  is  the  large  size  of  the 
cavity  in  which  it  is  lodged,  and  the  comparatively  small 
constricted  orifice  through  which  it  is  required  to  pass.  It 
might  be  to  some  extent  reasonably  assumed  that  what  could 
pass  through  the  cardiac  orifice  would  also  pass  through  the 
pyloric,  and  such  would  doubtless  be  the  case  could  the  body 
maintain  a  similar  disposition  of  its  axis  to  that  which  it  had 
in  entering  the  cavity.  A  large  object,  however,  is  almost 
certain  to  change  its  axis  after  it  has  passed  through  the 
cardiac  aperture,  and  such  an  alteration  may  render  it  a 
physical  impossibility  that  it  should  be  able  to  leave  the 
stomach,  by  the  pylorus.  Again,  there  are  some  structures 
which  neither  from  their  size  nor  irregular  shape  would  give 
rise  to  trouble,  but  being  sharp  pointed  are  liable  to  become 
engaged  in  the  mucous  folds  and,  from  the  active  contrac- 
tions of  the  stomach,  be  driven  inextricably  into  the  coats  of 
the  viscus. 

Symptoms. — Considerable  variations  exist  in  the  symptoms 
which  arise  when  a  body  becomes  retained  in  the  stomach. 
At  the  two  extremes  we  have  on  the  one  hand  an  almost 
entire  absence  of  symptoms,  on  the  other  manifestations  of 


166  THE   STOMACH 

the  most  acute  suffering  and  anxiety.  Pain,  when  experienced, 
varies  in  its  kind  and  in  its  intensity,  in  its  locahty  and  in  its 
duration.  A  determining  factor  in  the  patient's  sufferings 
is  the  nature  of  the  body  present.  Thus  when,  for  instance, 
this  consists  of  a  sohd  himp  of  metal,  a  sense  of  weight  or 
oppression  is  experienced  in  the  epigastric  region  ;  when  of  an 
irregular  or  sharp-pointed  material,  capable  of  injuring  the 
mucous  membrane,  pain  of  an  acute  character  is  felt.  The 
pain  experienced  may  be  circumscribed  or  localised,  felt  in 
front,  at  the  side,  or  behind.  It  may  radiate  and  appear 
more  diffused.  In  some  cases  it  is  increased  by  taking  food, 
due  in  all  probability  to  the  increased  peristaltic  action  induced 
by  ingestion.  In  other  cases  it  is  diminished,  when  the  ex- 
planation seems  to  be  that  the  distension  of  the  viscus  removes 
temporarily  the  wall  of  the  stomach  from  contact  with  the 
irritating  foreign  body.  Pressure  applied  externally  some- 
times causes  pain ;  and  in  a  similar  way  respiration,  for  the 
diaphragm  descends  in  each  inspiration  and  presses  upon  the 
stomach  from  above.  In  some  instances  the  pain  partakes 
somewhat  of  a  spasmodic  character.  At  one  time  free  from 
all  feeling  of  discomfort,  at  another  the  patient  is  seized  with 
pains  of  excessive  acuteness  and  intensity.  Vomiting  is  not 
a  constant  symptom,  but  when  present  and  the  ejecta  are 
tinged  with  blood,  laceration  of  the  mucous  membrane  is 
probable. 

Besides  these  local  symptoms  of  pain  and  occasional  vomit- 
ing, more  generalised  symptoms  will  be  present,  and  these  more 
or  less  in  proportion  to  the  severity  of  the  former.  In  the 
severer  cases  there  may  be  great  anxiety,  sleeplessness,  anorexia, 
thirst,  emaciation,  and  other  conditions  dependent  upon  a  dis- 
ordered digestion  and  an  insufficiency  of  nourishment.  There 
may  be  constipation  or  diarrhoea.  In  a  case  reported  by 
Sutton,'  the  presence  of  an  ascaris  lumbricoides  in  the  stomach 
gave  rise  to  choleraic  symptoms  which  immediately  dis- 
appeared on  the  ejection  of  the  worm.  In  a  very  unusual 
case  reported  by  Richter,^  the  pylorus  became  obstructed  by 
sarcinse  ventriculi,  causing  the  patient's  death.  In  cases  of 
prolonged  retention  without  great  severity  of  the  symptoms  at 

■  Lmicet,  1888,  vol.  i.  p.  368. 

^  Archiv  fiir  pathologische  Anatomie,  1887,  vol.  cvii.  p.  198. 


FOREIGN   BODIES  167 

the  outset,  secondary  complications  may  arise.  Perforation 
of  the  stomach  may  take  place.  If  no  adhesions  have  pre- 
viously formed,  acute  peritonitis  will  ensue ;  if,  on  the  other 
hand,  the  stomach  has  become  adherent  to  the  abdominal 
wall,  the  process  of  ulceration  which  is  going  on  may  lead 
either  to  the  formation  of  an  abscess  or  more  directly  to  a 
perforation  of  the  skin — in  both  instances  the  result  would  be 
a  gastric  fistula.  Hashimoto  '  records  a  case  where  a  tooth- 
brush had  been  extracted  after  fifteen  years'  retention  in  the 
stomach.  It  had  first  caused  an  abscess,  which,  bursting  ex- 
ternally, had  left  a  fistula.  Other  cases  are  mentioned  by  the 
same  surgeon  where  the  foreign  body  had  made  its  way  to 
more  distant  parts  of  the  organism,  being  finally  extracted,  or 
escaping  by  a  process  of  abscess  formation  and  ulceration. 

Diagnosis. — The  most  important  factor  in  diagnosis  is  the 
history  of  the  case.  Without  the  previous  knowledge  that  a 
foreign  body  has  been  swallowed,  it  is  practically  impossible 
to  state  from  the  symptoms  the  nature  of  their  true  cause. 

As  Poulet  ^  very  forcibly  shows,  '  We  can  scarcely  find  an 
authentic  case  in  the  entire  literature  in  which  the  diagnosis 
has  been  made  in  the  absence  of  a  history.'  Unfortunately 
the  majority  of  the  cases  in  which  this  accident  is  found  are 
either  lunatics,  drunkards,  or  children,  just  such  as  refuse,  or 
are  incapable  of  giving,  the  information  most  needed.  With, 
however,  a  history,  the  accompanying  symptoms  will  readily 
support  the  truth  of  the  patient's  statement,  and  little  doubt 
will  exist  in  the  surgeon's  mind  that  the  sufferings  experienced 
are  dependent  upon  the  retention  in  the  stomach  of  a  foreign 
body. 

In  exceptional  cases,  and  with  certain  kinds  of  foreign 
bodies,  it  is  possible  to  obtain  evidence  of  their  presence  in 
special  ways. 

In  one  or  two  instances  the  *  body  '  has  been  palpated 
through  the  abdominal  wall.  Lowson  ^  reports  a  case  in  which 
a  lunatic  had  swallowed  a  skewer.  It  was  felt  projecting 
below  the  eighth  costal  cartilage.     Beck  "*  also  felt  externally 

'  Archiv  fur  klinische  Chirurgie,  1888,  vol.  xxviii.  p.  169. 
^  Foreign  Bodies  in  Surgery,  vol.  i.  p.  155. 
^  Brit.  Med.  Journ.  1893,  vol.  i.  p.  116. 
*  Ibid.  Epitome,  1894,  vol.  ii.  p.  82. 


168  THE   STOMACH 

penknives  which  had  been  swallowed.  It  is  sometimes  possible 
to  strike  the  substance  within  the  stomach  by  the  passage 
of  an  oesophageal  sound  ;  in  the  case  just  quoted,  this  was 
done. 

In  a  case  recorded  by  Cant,'  the  patient  stated  that  she 
had  swallowed  a  razor  ;  the  fact  was,  however,  doubted  by  her 
friends.  Twenty  drops  of  hydrochloric  acid  were  administered. 
An  hour  after  the  stomach  was  washed  out ;  the  washings 
were  collected,  filtered,  evaporated  down,  and  redissolved. 
The  presence  of  iron  in  large  quantity  was  shown  by  the  Prus- 
sian blue  test. 

Another  means  of  determining  the  existence  of  a  metallic 
body  in  the  stomach  is  by  magnetism.  Pollailon  ^  confirmed 
a  suspicion  of  the  kind  in  a  case  where  it  was  believed  the 
patient  had  swallowed  a  table-fork.  He  placed  near  the  epi- 
gastrium a  delicate  magnetic  needle,  and  found  that  it  was 
distinctly  deflected.  By  another  method  a  powerful  electro- 
magnet was  placed  close  to  the  abdominal  wall.  On  closing 
the  circuit  an  arching  of  the  skin  was  produced,  as  if  a  body 
within  the  abdomen  were  being  attracted  towards  the  poles. 
By  a  third  process  a  suspended  electro-magnet  oscillated 
towards  the  abdomen  whenever  the  current  was  passed.  At 
the  meeting  of  the  Paris  Academy  of  Medicine  at  which  the 
above  case  was  discussed,  Pollailon  and  Goubaux  suggested 
that  by  means  of  inducing  vomiting  it  might  be  possible  to  so 
dilate  the  cardiac  orifice  that  a  metallic  substance  might  be 
extracted  by  way  of  the  oesophagus  by  means  of  a  powerful 
electro-magnet. 

Prognosis. — One  of  four  things  must  happen  :  (1)  the  '  body ' 
will  be  ejected  through  the  month ;  (2)  it  will  pass  through 
the  pylorus  ;  (3)  it  will  remain  an  indefinite  time  in  the 
stomach  ;  (4)  it  will  work  its  way  through  the  stomach  and 
make  its  exit  somewhere  through  the  skin.  Of  these,  the 
commonest  result  most  fortunately  is  the  ultimate  passage  of 
the  body  through  the  i)ylorus.  It  need  hardly  be  said  that 
before  any  opinion  can  be  expressed  as  to  the  probable  course 
a  foreign  body  will  take,  there  must  first  exist  an  accurate 
knowledge  of  the  nature  of  the  body  swallowed.     Given  two 

'  Brit.  Med.  Journ.  1893,  vol.  i.  p.  13. 
^  Extract  in  Lancet,  1886,  vol.  ii.  p.  5t2. 


rolIEKiN    r>()l)IES  169 

cases,  in  one  of  which  a  fork  has  been  swallowerl,  and  in  tlie 
other  a  coin,  it  would  be  reasonable  to  expect  that  the  coin 
might  pass  through  the  pylorus,  bat  it  would  be  very  doubtful 
whether  such  a  course  would  be  taken  by  the  fork. 

The  two  practical  questions  which  the  surgeon  has  to 
answer  are,  first,  whether  there  is  a  chance  of  the  foreign  body 
making  its  way  out  of  the  body  'per  vias  natiiralea,  with  the 
assistance  possibly  of  some  medicinal  or  dietetic  measures  ; 
or,  second,  whether  the  only  chance  of  removal  must  be  by 
operation.     This  naturally  leads  to  the  question  of  treatment. 

Treatment. — The  conservative  measures  consist  in  attempt- 
ing to  get  the  body  ejected  by  the  mouth  or  passed  on  into 
the  bowel ;  the  operative,  in  the  extraction  of  the  body 
through  an  artificial  opening  made  through  the  abdominal 
parietes  and  the  stomach  wall. 

With  regard  to  attempts  to  remove  the  '  body  '  through 
the  mouth,  there  are  comparatively  few  cases  in  which  it  would 
be  wise  to  induce  emesis  of  a  character  more  frequent  and 
more  energetic  than  that  which  may  possibly  exist  as  a  sym- 
ptom. The  nature  of  the  substance  will  determine  the  question 
whether  or  not  the  trial  should  be  made.  It  can  easily  be 
understood  that  to  attempt  by  this  means  to  remove  a  body 
which  has  passed  perhaps  with  difficulty  into  the  stomach,  is 
only  likely  to  court  the  greater  danger  of  its  becoming  seriously 
impacted  within  the  oesophagus. 

Endeavours  to  get  the  body  to  take  the  natural  course 
of  exit  through  the  pylorus  must  entail  considerations 
which  affect  on  the  one  hand  the  patient,  and  on  the  other 
the  foreign  body  itself  within  the  stomach.  Eecumbency 
should  be  enforced,  and  the  patient  made  to  lie  as  much  as 
possible  on  the  right  side,  in  order  to  place  the  pyloric  orifice 
in  the  most  dependent  position.  Any  pain,  spasms,  or 
gastric  irritability  should  be  relieved  by  the  administration  of 
narcotics,  preferably  opium.  The  nourishment  of  the  patient 
forms  an  essential  part  of  the  process  of  cure.  Substances 
are  given  which  will  be  likely  either  to  form  a  mass  with  the 
'  body,'  and  so  dilate  the  pyloric  orifice  sufficiently  to  admit  of 
its  passing  ;  or  to  lubricate  it,  or  to  entangle  it  in  such  a  way 
that  in  both  instances  its  onward  passage  will  be  facilitated. 
Among  the  first  class  are  potatoes,  constituting  the  well-known 


170  THE    STOMACH 

potato  curefrice,  porridge,  &c. ;  among  the  latter  sre  oils, 
fats,  and  thick  glutinous  drinks.  As  an  example  of  the 
nature  of  entangling  the  object  in  some  shreddy  material 
may  be  mentioned  a  case  recorded  by  Dickson. ^  The  patient, 
a  lady,  had  swallowed  a  plate  of  false  teeth  during  the  night. 
She  was  made  to  swallow  a  small  amount  of  oakum  and  a 
large  number  of  figs  and  raisins.  The  treatment  was  continued 
for  a  week,  when  she  suddenly  felt  rehef,  and  a  few  hours 
after  passed  the  teeth  per  anum.  The  irregularities  of  the 
false  teeth  were  found  to  have  been  rendered  somewhat 
smoother  by  the  oakum  and  bits  of  the  fig,  which  had  become 
adherent  to  them.  Pisko  ^  reports  the  case  of  a  baby,  11^ 
months  old,  in  which  the  potato  cure  was  followed  by  the 
evacuation  by  the  bowel  of  a  steel  screw  that  had"  been 
swallowed.  For  several  days  the  infant  was  fed  only  on  pota- 
toes. A  laxative  was  then  given,  when  the  screw,  imbedded 
m  fasces,  was  easily  and  painlessly  passed.  Solis-Cohen  =* 
reports  a  case  in  w^hich  the  same  treatment  was  adopted. 
After  two  days  an  irregularly  shaped  dental  clasper  was  suc- 
cessfully passed.  Beck-*  instances  the  case  of  a  man  who  was 
m  the  habit  of  swallowing  penknives.  Gastrotomy  was  per- 
formed, and  the  knives  successfully  removed.  He,  however, 
agam  got  into  trouble  by  swallowing  two  penknives,  and  on 
this  occasion  food  with  abunda.nt  solid  residue  was  given.  In 
eight  days  one  penknife  was  passed,  and  seven  days  later  the 
second  came  away. 

When  the  foreign  body  is  a  metal  structure  of  some  kind, 
and  especially  if  it  be  composed  of  iron  or  steel,  the  question 
arises  of  the  possibility  of  lessening  its  size  by  some  solvent 
action.  Independently  of  artificial  means,  iron  or  steel  under- 
goes considerable  changes  due  to  the  action  of  the  gastric 
juice  alone.  Numerous  instances  are  now  on  record  and 
specimens  forthcoming  to  show  the  marked  corrosive  action 
of  the  normal  gastric  secretion.  A  number  of  knives  are 
exhibited  in  the  museum  of  Guy's  Hospital,  London,  which 
were  removed  from  the  stomach  of  a  man  who  for  years 
prior  to  his  death  had  been  in  the  habit  of  performing  in 

'  Edinburgh  Med.  Journ.  1876,  p.  839. 

2  Solis-Cohen,  Annual  of  the  Universal  Medical  Sciences,  189?,  vol.  i.  C— 17. 

^  ^bid-  *  Brit  Med.  Journ.  Epitome,  1894,  vol.  ii.  p.  82. 


I'OlMCKiN    r.ODIES  171 

this  way  with  the  ohject  of  making  money.  It  is  possible, 
however,  to  accelerate  this  normal  action  of  the  gastric  juice 
by  administei'ing  drinks  containing  citric  or  tartaric  acid. 

Our  last  resource  in  treatment  is  by  operation,  and  surgeons 
nowadays  would  prefer  to  make  use  of  this  severe,  yet  fortu- 
nately comparatively  safe,  procedure,  to  spending  time  in 
trying  conservative  measures  which  in  most  instances  must 
hold  out  a  very  doubtful  result.  The  operation  of  gas- 
trotomy  has  now  been  frequently  performed  for  the  extraction 
of  foreign  bodies,  and,  so  far  as  the  recorded  cases  are  con- 
cerned, with  almost  unbroken  success.  Bernays  '  gives  a  table 
of  thirteen  cases  in  which  gastrotomy  was  performed.  Only 
two  failed  to  make  a  speedy  recovery,  and  in  both  there  were 
complications  which  sufficiently  explained  the  reason.  Little 
hesitation  therefore  need  exist  in  the  mind  of  the  surgeon 
as  to  the  right  course  of  action  to  adopt  when  once  he  is 
satisfied  that  there  is  a  poor  chance  of  the  foreign  body 
finding  a  speedy  exit  by  any  other  means. 

I  must  not  conclude  the  subject  of  gastric  foreign  bodies 
without  referring  the  reader  to  the  exhaustive  article  upon  it 
by  Poulet,  in  his  own  work  on  '  Foreign  Bodies  in  Surgical 
Practice.'  A  much  more  extensive  and  interesting  resume  of 
tlie  subject  will  be  found  there  than  it  has  been  possible  to 
introduce  here. 

Case  XL VII. —  The  existence  of  a  razor  in  the  stomach. 
Laparotomy.     Death  from  hcemophilia. 

Mrs.  S.,  aged  68,  was  admitted  into  the  Lincoln  County  Plospital, 
having  attempted  to  destroy  her  life  by  swallowing  a  razor.  There  were 
no  symptoms,  and  no  signs  of  the  razor  could  at  first  be  detected. 
Although  the  patient  herself  maintained  that  she  had  swallowed  it,  her 
friends  refused  to  believe  this.  The  Prussian  blue  test  was  tried  (see 
above),  with  the  result  that  the  presence  of  iron  in  the  stomach  was  con- 
firmed. On  the  morning  of  the  fifth  day  after  admission,  the  end  of  the 
razor  could  clearly  be  felt  fixed  at  the  pyloric  end  of  the  stomach.  On 
the  evening  of  the  same  day  she  vomited  and  suffered  slight  pain.  On 
the  sixth  day  gastrotomy  was  performed.  The  razor  was  foimd  lying 
lengthwise  in  the  stomach,  the  narrow  end  in  the  cardiac  I'egion.  The 
woman  died,  five  days  after  the  operation,  from  haemorrhagic  exhaustion. 
She  was  a  '  bleeder,'  and  had  lost  much  blood  before  the  operation. 
(W.  J.  Cant,  'Brit.  Med.  Journ.'  1893,  vol.  i.  p.  13.) 

'  Annals  of  Surgery,  1887,  vol.  v.  p.  128. 


172  THE    STOMACH 

G-a^trolith-s  and  Hair  tamoTirs. — These  are  two  forms  of 
foreign  bodies  -vrliich  deserve  separate  notice.  They  are  of  the 
nature  of  concretions,  and  owe  their  origin  and  existence  to 
the  special  conditions  nnder  which  they  are  formed. 

Gistroliths. — Little  is  known  as  to  the  real  origin  of  these 
bodies.  In  some  cases  it  would  appear  that  the  nucleus  is 
formed  of  hair,  and  around  this  has  been  built  up  a  structure 
of  vegetable  material.  In  other  cases  no  such  definite  form 
of  a  nucleus  is  observable.  In  a  case  reported  by  Kooyker,'  a 
mass  was  found  in  the  stomach,  twenty-eight  ounces  in  weight, 
no  nucleus  was  present,  and  on  microscopical  examination  it 
was  found  to  be  composed  of  starch  granules,  jAant  tissues, 
cells,  and  vascular  bundles  containing  chlorophyll.  A  case 
of  similar  nature  is  referred  to  by  Langenbuch  in  1884. 

Hair  tumours. — Tumours  composed  entirely  of  hah  are 
more  frequently  met  with  than  gastroHths.  Not  a  few  have 
now  been  recorded.  Knowsley  Thornton  ^  in  1886  reported  a 
case  in  which  he  had  successfully  removed  a  mass  of  hair 
weighing  two  pounds.  He  refers  to  a  similarly  successful  case 
of  removal  by  Professor  Schonborn.  In  this  latter  instance 
the  hair  baU  weighed  nine  or  ten  ounces.  Several  other  cases 
are  referred  to  in  the  remarks  that  follow.  In  these,  death 
occurred  mostly  from  peritonitis  dependent  on  ulceration 
and  perforation.  The  cases  quoted  are  those  of  Bardamant, 
PoUock,  May,  Piitchie,  PkUsseU,  Inman,  and  Best.  Later  a 
tliird  successful  case  of  gastrotomy  for  this  form  of  body  was 
recorded  by  Berg.-^  The  tumour  weighed  about  thirty  ounces. 
At  a  still  later  date  a  case  is  reported  by  Ballinger.*  The 
patient  was  a  girl  aged  16.  Death  resulted  from  exhaustion. 
At  the  i>ost  mortem  a  great  mass  of  hair  was  found  distending 
the  stomach  and  duodenum.  At  the  Clinical  Society  of 
London,  in  1871,  GuU-^  showed  a  specimen  of  a  hair  tumour 
weighing  five  and  three-quarter  ounces.  It  was  composed  of 
string,  thread,  cotton  wool,  and  hair  of  three  colours — the  hair 
of  the  patient's  own  head  and  that  of  her  two  children. 

There  are  therefore,  so  far  as  I  have  been  able  to  ascertain, 

•  Annttal  of  the  Universal  Medical  Sciences,  1B92,  vol.  i.  C— 16. 
2  Lancet,  1886,  vol.  i.  p.  57. 

'  Annual  of  tlie  Universal  Medical  Sciences,  1889,  vol.  i.  C  — 23. 

♦  Ibid.  1892,  vol.  i.  C— 16. 

*  Trans.  Clin.  Soc.  Land.  1871,  vol.  iv.  p.  180. 


GASTEOLITIIS    AND   HAIE   TUMOURS  173 

eleven  eases  on  record  of  this  kind  of  foreign  bodj.  In  three 
of  them  the  masses  of  hair  were  removed  successfully  by 
gastrotomy ;  while  in  the  others  death  resulted  from  causes 
connected  either  with  imperfect  nutrition,  or  more  directly 
from  ulceration  and  perforation  of  the  stomach  wall. 

Sjrmptoms. — These  present  considerable  variety,  but  are 
mostly  connected  with  some  form  of  gastric  disturbance.  The 
patient  suffers  from  nausea,  vomiting,  anorexia  with  con- 
secutive emaciation,  weakness,  and  exhaustion  ;  there  may 
be  marked  dyspncea.  In  most  cases  there  appears  to  have 
been  a  total  absence  of  symptoms  at  an  early  stage:  it  is 
only  when  the  mass  has  increased  to  a  considerable  size  that 
indications  of  some  gastric  irritation  manifest  themselves. 
In  Balhnger's  case  the  patient  suffered  from  gastro-iutestinal 
catarrh,  with  Kquid  stools,  for  two  and  a  haK  years.  "When 
the  mass  reaches  a  sufficient  size,  it  can  be  felt  as  a  tumour 
through  the  parietes. 

Diagnosis. — ^There  is  nothing  sufficiently  distinctive  about 
the  symptoms  to  lead  one  to  surmise  the  nature  of  their  true 
cause.  "When  it  has  been  possible  to  feel  a  tumour  by  abdominal 
palpation,  it  has  usually  been  diagnosed  as  a  mahgnant  growth. 
In  aU  the  cases  recorded  there  has  been  a  history  in  early  Hfe 
of  a  habit  of  swallowing  hair,  which  in  more  than  one  instance 
has  been  continued  on  into  adult  years.  The  previous  know- 
ledge of  such  a  habit,  with  the  co-existence  of  a  tumour  in 
the  gastric  region,  should  excite  a  suspicion  as  to  the  possible 
nature  of  the  complaint. 

Treatment. — There  is  little  to  say  with  reference  to  the 
measures  which  should  be  adopted  in  the  event  of  a  correct 
diagnosis  being  made.  The  sooner  the  body  is  removed  by 
gastrotomy  the  better. 


CHAPTER   XXI 

DISEASE.       ULCER 


UxLTKE  disease. of  the  cesophagus,  there  are  comparativelv 
few  of  the  various  complaints  which  affect  the  stomach  that 
call  for  any  consideration  or  interference  on  the  part  of  the 


174  THE   STOMACH 

surgeon.  In  the  case  of  the  cesophagas  it  has  been  shown 
that  disease,  whether  inflammatory  or  non-inflammatory,  is 
almost  certain  to  give  rise  to  symptoms  of  an  obstructive 
character,  and  these,  if  they  do  not  actually  call  for  surgical 
interference,  will  very  frequently  require  a  surgeon's  opinion. 
In  dealing  therefore  with  diseases  of  the  stomach,  only  such 
will  be  discussed  as  are  likely  to  call  for  surgical  treatment. 
It  would  be  supererogatory  to  trench  upon  ground  which  in 
more  than  one  sense  is  so  essentially  within  the  domain  of 
the  physician.  In  almost  every  case  it  is  the  physician  who 
first  sees  and  diagnoses  these  forms  of  disease.  The  surgeon's 
opinion  is  required  not  so  much  to  discuss  the  nature  of  the 
disease,  as  to  state  what  he  is  prepared  to  do,  how  he  will  do 
it,  and  with  what  possible  result. 

It  is  only  within  the  last  few  years  that  the  surgeon  has 
come  to  the  assistance  of  the  physician  in  the  treatment  of 
certain  diseases  of  the  stomach.  It  may  therefore  be  said 
that,  reasoning  in  the  light  of  the  successful  incursions  made 
by  surgery  in  other  departments  of  medicine,  there  yet  exists 
a  sphere  of  labour  for  the  surgeon  far  beyond  his  present 
limited  field  of  operation.  It  is  not,  I  venture  to  think,  too 
venturesome  to  predict  that  the  day  is  not  far  distant  when 
the  stomach  will  be  opened,  explored,  and  resutured  for  purely 
diagnostic  purposes  with  as  much  freedom  and  security  as  is 
now  done,  for  instance,  in  the  case  of  the  brain.  I  cannot 
perhaps  better  illustrate  such  purely  exploratory  operations 
than  by  quoting  two  cases  recorded  respectively  by  Bradford 
and  Treves.  It  is  true  the  operation  was  performed  with  the 
belief  that  the  patients  were  suffering  from  ulcer  of  the  stomach. 
In  Bradford's  case  the  symptoms  pointed  unmistakably  to  such 
an  affection.  As  will  be  seen,  however,  the  operations  proved 
to  be  in  their  results,  though  not  in  their  object,  purely 
exploratory  ones.  The  patients,  who  were  aged  25  and  40, 
made  uninterrupted  recoveries,  and  were  restored  to  perfect 
health. 

Case  XL VIII. — Exiiloration  of  stomach  by  gastrotomy  for  supposed 

ulcer :  nothing  found,  hut  patient  covijjletely  restored  to  health. 

An  incision  was  made  in  the  median  line  from  the  xiphoid  cartilage 

downwards.     The  stomach  was  found  somewhat  distended,  but  without 

thickening.     Tlie  appearance  of  the  viscixs  was  perfectly  normaL     Two 


DISEASE  175 

finjfers  were  inserted  into  the  abdominal  wound,  the  anterior  surface 
palpated,  but  no  thickeninji;s  or  adhesions  were  discovered.  The  stomach 
was  pulled  from  one  side  to  the  other  so  that  the  whole  anterior  surface 
could  be  palpated  without  dithculty.  The  lesser  cavity  of  the  peritoneum 
between  the  stomach  and  the  large  intestine  was  opened  a  short  distance 
from  the  border  of  the  former,  two  fingers  inserted  beneath  the  stomach, 
and  two  fingers  of  the  other  hand  placed  so  as  to  palpate  the  anterior 
surface.  Between  the  two,  the  posterior  surfaces  of  the  stomach  could  be 
extensively  and  thoroughly  explored  and  also  any  thickening  ascertained. 
No  adhesions  were  found  on  the  posterior  surface,  and  nothing  that  was 
abnormal  observed.  The  stomach  was  then  incised,  in  order  to  see  if  any 
small  ulcerations  existed.  An  electric  light  was  inserted  and  the  inner 
side  of  the  stomach  was  easily  seen,  but  neither  by  this  nor  by  the  fingers 
could  anything  abnormal  be  determined.  The  wounds  were  therefore 
sewn,  and  dressed  with  the  ordinary  aseptic  dressings.  The  patient 
made  a  good  recovery  and  was  relieved  of  all  the  symptoms.  (Bradford, 
'  Trans.  American  Surgical  Association,'  1892,  vol.  x.  p.  219.) 

Case  XLIX. — A  man  aged  40  years,  who  was  admitted  to  the  London 
Hospital,  had  been  ill — according  to  his  own  report — for  twelve  years, 
with  pain  in  the  stomach  and  vomiting.  He  had  vomited  blood.  He 
was  greatly  emaciated.  The  pain  in  the  stomach  was  evidently  very 
severe.  The  stomach  was  exposed  by  operation  on  October  11.  It  was 
much  enlarged,  but  exhibited  no  abnormal  appearance  beyond  this.  The 
stomach  was  then  opened  and  emptied.  The  pylorus  was  examined  from 
within,  and  every  part  of  the  gastric  surface  explored.  No  ulcer  or  other 
morbid  condition  was  discovered.  The  gastric  and  abdominal  wounds 
were  closed.  The  patient  recovered  well,  and  all  pain  in  the  stomach 
has  now  (January  1896)  practically  disappeared.  (Frederick  Treves, 
'  Lancet,'  1896,  vol.  i.  p.  18.) 

Mayo  Eobson,^  in  presenting  to  the  Clinical  Society  of 
London  two  patients  whom  he  had  successfully  operated 
upon  for  adhesion  of  the  stomach,  gave  utterance,  in  the 
course  of  his  remarks,  to  the  following  sentiment,  which  may 
not  inaptly  he  quoted  in  support  of  exploratory  operations : 
'  Although  it  was  difficult  to  lay  down  any  hard  and  fast  rules, 
yet  personally  he  should  feel  it  wise,  in  cases  of  obscure 
abdominal  pain  producing  invalidism  or  debility  after  medical 
treatment  had  been  fully  tried  and  failed,  to  open  the  abdomen 
in  order  to  clear  up  the  diagnosis,  and  then  to  adopt  that  line 
of  treatment  which  seemed  to  be  indicated.' 

The  diseases,  or  certain  phases  of  them,  which  up  to  the 
present  time  have  received  some  form  of  surgical  treatment  are 
— ulcer,  carcinoma  and  other  tumours,  stenosis  of  the  pylorus, 

'  Trans.  Clin.  Soc.  Lond.  1894,  vol.  xxvii.  p.  1. 


176  THE   STOMACH 

dilatation,  and  certain  external  conditions,  where,  either  by 
pressure  as  in  the  case  of  tumours,  or  by  distortion  as  effected 
by  adhesions,  various  gastric  disturbances  have  been  caused. 
These  will  now  be  discussed  in  the  order  here  given. 

Ulcer. — While,  for  reasons  above  stated,  it  is  unnecessary 
for  the  surgeon  to  be  acquainted  with  all  the  symptoms  which 
indicate  ulcer  of  the  stomach,  it  is  of  some  importance  that 
he  should  be  familiar  with  certain  pathological  aspects  of 
the  disease.  The  first  consideration  worthy  of  his  attention 
concerns  the  ulcer  itself,  and  the  second  the  various  complica- 
tions which  may  arise  in  connection  with  it. 

Excluding  ulcers  the  result  of  traumatism,  and  such  rarer 
forms  as  are  sometimes  associated  with  syphilis  and  tuber- 
culosis, the  form  to  be  dealt  with  here  is  the  so-called  simple 
or  chronic  ulcer  of  the  stomach.  It  is  '  simple '  from  the  fact 
that,  so  far  as  is  known,  its  origin  is  unconnected  with  other 
than  local  conditions ;  and  it  is '  chronic '  from  the  slow 
progress  of  the  ulceration.  There  are,  however,  exceptions  to 
both  these  conditions.  In  some  cases  it  would  seem  that  a 
predisposing  cause  at  least  is  to  be  found  in  some  constitutional 
disturbance  ;  and  the  progress  of  the  ulcer  has  been  known  to 
run  a  very  rapid  course. 

As  most  frequently  met  with,  the  ulcer  varies  in  size  from 
a  sixpence  to  a  shilling ;  it  presents  a  somewhat  punched-out 
appearance,  with  more  or  less  thickened  edges,  and  a  base 
which  is  thin  or  thick  in  proportion  to  the  depth  to  which 
ulceration  has  taken  place  and  adhesions  have  formed.  In 
situation  the  ulcer  is  most  frequently  found  either  at  the 
greater  curvature  or  somewhere  close  to  the  pylorus.  It  is 
much  less  frequently  met  with  on  either  the  anterior  or 
posterior  wall,  and  least  often  at  the  cardiac  orifice. 

In  the  process  of  healing,  considerable  contractions  some- 
times take  place ;  not  only  may  the  stomach  become  dilated  in 
parts,  but  fibrous  bands  may  be  present  and  culs-de-sac  created. 
The  most  serious  results  which  may  accrue  from  cicatrisation 
are  those  connected  with  a  distortion  or  contraction  of  the 
pylorus.  This  complication  will  be  more  particularly  referred 
to  later. 

In  the  opposite  process,  that  of  progressive  ulceration,  one 
or  more  of  several  issues  may  happen,  depending  chiefly  on 


\ 


f 


\~. 


Fig.  14— Perforating  Ulcer  of  Stomach.— The  ulcer  is  situated  in  the  lesser 
curvature  anj  posterior  wall  of  the  stomach.  It  is  oblong  in  shape,  and 
possesses  thin  rounded  edges.  Adhesions  e.xisted  at  the  floor  of  the  ulcer, 
but  these  had  become  perforated      (R.l.M.,  Glas.) 


LJAIEli  177 

the  situation  of  the  ulcer  and  the  acuteness  of  the  process. 
In  any  case  perforation  of  the  stomach  will  take  place.  When 
the  process  is  slow,  adhesions  are  contracted  between  the  floor 
of  the  ulcer  and  neighbouring  structures.  On  the  other  hand, 
when  ulceration  progresses  rapidly,  a  communication  is  esta- 
blished between  the  cavity  of  the  stomach  and  the  general 
abdominal  cavity,  with  all  the  untoward  results  which  accrue 
from  such  a  connection. 

When  once  the  stomach  wall  is  perforated,  and  the  floor  of 
the  ulcer  formed  by  neighbouring  organs  to  which  it  has  become 
adherent,  one  of  two  conditions  will  result — that  is,  supposing 
the  ulcerative  process  is  progressive — either  a  fistulous  opening 
will  be  established  between  the  stomach  and  a  neighbouring 
viscus,  or  an  abscess  will  be  formed  which  may  rupture,  and 
thus  cause  indirectly  complications  similar  to  those  arising 
from  progressive  ulceration  independent  of  suppuration.  As 
to  what  organs  may  be  involved  in  one  or  other  of  these 
processes  is  merely  a  matter  of  anatomical  detail.  Suffice  it 
to  say  that  instances  have  been  recorded  illustrative  of  in- 
volvement of  every  part — viscus  or  cavity — with  which  the 
stomach  has  anatomical  relations. 

In  discussing  those  aspects  of  ulcer  of  the  stomach  which 
may  be  said  to  possess  features  of  some  surgical  interest,  it 
may  be  well  for  me  to  preface  my  remarks  with  a  few  words 
of  caution.  The  disease  is  one  that  in  most  of  its  aspects 
essentially  requires  rest  and  not  interference.  Hence  it  is 
only  when  all  reasonable  conservative  measures  have  been 
applied  without  avail  that  the  physician  should  consult  the 
surgeon,  and  the  latter  should  be  prepared  to  act.  The  follow- 
ing events  in  the  life  history  of  the  disease  may  be  said  to 
be  worthy  of  the  surgeon's  attention :  1.  The  character  of 
the  ulcer ;  2.  the  occurrence  of  excessive  hemorrhage ;  3.  per- 
foration  into  the  peritoneal  cavity ;  4.  formation  of  abscess ; 
5.  fistulous  communications  ;  6.  adhesions ;  7.  internal  con- 
traction ;    8.  pyloric  stenosis. 

1.  Regarding  the  character  of  the  idcer. — So  far  as  the  ulcer 
itself  is  concerned,  the  surgeon's  interest  centres  upon  the 
possibility  of  its  removal.  Whether  such  a  question  in  treat- 
ment is  to  be  entertained  is  one  for  the  physician  originally 
to  decide. 


178  THE   STOMACH 

Assuming  that  the  chronicity  of  the  case  and  other  features 
suggest  the  advisabihty  of  the  endeavour,  the  surgeon  will  be 
assisted  in  Lis  opinion  as  to  its  practicability  by  some  know- 
ledge as  to  the  situation  of  the  ulcer.  "When  located  near 
the  pylorus,  it  is  in  some  instances  possible  to  detect  a 
tumour.  It  may  be  incidentally  remarked  here  that  mis- 
taken diagnoses  have  not  infrequently  been  made  from 
always  connecting  a  swelling  or  tumour  in  the  region  of  the 
pylorus  with  carcinoma  of  that  region.  Numerous  cases  are 
recorded  to  show  what  an  amount  of  inflammatory  thickening 
is  sometimes  associated  with  ulcer  near  the  pylorus.  The 
detection  therefore  of  such  a  tumour  in  this  region  should  not 
be  allowed  to  mislead  when  the  earlier  symptoms  unmistak- 
ably point  to  ulcer.  When  the  ulcer  is  situated  in  any  other 
part  of  the  stomach,  it  is  very  rarely  possible  to  detect  its 
existence  by  palpation  through  the  abdominal  parietes. 

Ord  ^  thinks  that  the  time  at  which  pain  occurs  after 
taking  food  may  throw  some  light  upon  the  position  of  the 
ulcer.  Thus  when  it  arises  shortly  after  taking  food,  or  even 
during  a  meal,  the  ulcer  is  probably  in  the  cardiac  region  of 
the  stomach.  When  occurring  later,  pain  in  all  probability 
marks  increasing  distance  in  the  position  of  the  ulcer  from 
the  cardiac  orifice.  Other  conditions,  however,  affecting  the 
patient  and  the  stomach  generally  have  to  be  taken  into 
account  in  considering  the  relative  value  of  pain  with 
reference  to  the  localisation  of  the  ulcer.  The  co-existence, 
for  instance,  of  simple  hyperaesthesia,  or  catarrh,  would  in  all 
probability  give  rise  to  considerable  discomfort,  amounting 
not  infrequently  to  pain,  immediately  after  food  entered  the 
stomach. 

Again,  the  period  at  which  vomiting  occurs  after  ingestion 
may  to  some  extent  indicate  the  position  of  the  ulcer.  Early 
vomiting  after  food  may  indicate  implication  of  the  cardiac 
region  ;  but  when  occurring  later,  and  still  more  when  it  arises 
after  several  successive  meals,  the  ulcer  may  be  considered 
as  located  in  the  pyloric  region.  The  attitude  of  patients 
during  the  paroxysms  of  pain  is  also  sometimes  helpful  in 
suggesting  the  seat  of  the  lesion.  Thus  the  patient  will 
probably  assume  such  a  position  as  will  tend  to  obviate  the 

»  International  Journal  of  the  Medical  Sciences,  1889,  vol.  i.  jj.  552. 


ULCER  179 

pressure  and  irritatinp;  effect  of  the  inp,esta  upon  the  ulcer. 
Tlie  dorsal  position  would  he  that  likely  to  l)e  adopted  hy  a 
patient  with  an  ulcer  located  on  the  anterior  wall  of  the 
stomach,  and  rice  versa.  Similarly  a  patient  might  find 
greater  relief  in  lying  on  the  left  side  when  the  ulcer  is  situated 
ahout  the  pylorus,  and  vice  versa. 

With  all  the  aid,  however,  that  can  be  derived  from  such 
suggestive  symptoms,  the  only  absolutely  certain  knowledge 
of  the  situation  of  the  ulcer,  and  the  possibility  of  its  removal, 
can  be  obtained  from  an  exploratory  laparotomy.  For  although 
we  may  approach  beforehand  to  within  a  measurable  distance 
of  practical  certainty  as  to  the  situation  of  the  ulcer,  it  still 
remains  impossible  for  us  to  decide,  prior  to  oj)eration,  whether 
there  are  or  are  not  adhesions  of  such  a  character  as  renders 
removal  impracticable.  Again,  there  is  always  the  pospibility 
of  more  than  one  ulcer  being  present.     (See  Plate  VIII,  fig,  15,) 

Assuming  that  the  ulcer  is  single,  suitably  located,  and  not 
inseparably  connected  with  any  important  structures,  its  suc- 
cessful removal  may  fairly  be  entertained.  The  conditions, 
however,  with  which  the  surgeon  is  almost  always  more  likely 
to  be  confronted  are  not  those  most  favourable  for  the  success 
of  his  operation,  but  just  those  where  the  greatest  difficulties 
are  liable  to  exist.  Thus  it  is  only  after  protracted  endeavours 
by  various  conservative  measures,  and  the  failure  of  these, 
that  his  aid  is  called  in ;  and  then  he  has  to  deal  with  an  ulcer 
which  will  only  too  likely  be,  if  not  extensive  in  area,  at  least 
very  extensive  in  the  results  it  has  produced  in  its  immediate 
vicinity.  If  located  posteriorly,  it  will  be  intimately  bound 
down  to  the  pancreas  ;  if  near  the  pylorus,  there  will  possibly  be 
contortion  of  that  orifice,  with  probably  some  obstruction  from 
inflammatory  infiltration  and  induration  ;  and  if  in  a  part  of 
the  stomach  where  the  relations  of  the  viscus  are  freer, 
serious  contraction  and  alterations  in  its  shape  may  already 
have  taken  place.  The  surgeon  therefore  will  have  to 
decide,  from  the  conditions  found  after  a  careful  physical 
examination  of  the  stomach  through  an  abdominal  incision, 
whether  he  deems  it  wise  to  proceed  further  and  attempt 
some  plastic  operation  or  anything  so  radical  as  excision. 
Suffice  it  to  say  that  not  a  few  cases  are  now  on  record 
where    successful  excisions   have   been    performed.      As    ex- 

N  2 


180  THE   STOMACH 

amples  may  be  mentioned  the  following :  A  successful  case 
by  van  Kleef ;  '  and  another  by  Postempski  of  Eome,  quoted 
by  Bradford,^  One  successful  excision  has  been  reported  from 
Billroth's  Clinique.^  In  this  case  the  stenosed  pylorus  was 
also  removed.  Maurer''  also  successfully  excised  an  ulcer. 
Lange  ^  succeeded  in  excising  a  very  large  ulcer.  The  hard  disc 
in  the  anterior  wall  of  the  stomach  measured  from  four  to  five 
inches  in  diameter,  of  which  the  ulcer  itself  occupied  a  central 
area  about  three  inches  in  diameter.  The  patient  was  a 
butcher  aged  '25  years,  and  was-  dismissed  from  the  hospital 
about  four  weeks  after  the  operation. 

2.  Excessive  hcemorrhage. — Hgemorrhage  is  far  from  being  a 
constant  symptom  in  ulcer  of  the  stomach,  occurring  apparently 
in  less  than  fifty  per  cent,  of  the  cases.  Still  less  frequently 
does  it  occur  with  any  degree  of  severity.  It  is,  however,  in 
some  of  these  severe  cases  that  surgery  may  lend  valuable 
assistance.  '  When  violent  haemorrhage,'  says  Ewald,'  has  once 
set  in,  the  danger  of  its  recurrence  hangs  like  the  sword  of 
Damocles  over  the  head  of  the  patient.'  Fatal  haemorrhage 
appears  to  be  comparatively  rare,  and  possibly  in  many,  if 
not  in  most,  of  these  cases  death  will  be  unpreventable,  what- 
ever the  measures  employed.  It  is  unlikely  that  where  either 
the  splenic  artery  or  the  portal  vein  has  been  opened  into, 
and  still  more  so  when  the  left  ventricle  of  the  heart  has 
been  perforated,  that  any  means  at  our  disposal,  medical  or 
surgical,  could  prevent  an  untoward  result.  Short,  how- 
ever, of  haemorrhage  from  such  sources,  where  death  must  ra- 
pidly ensue,  severe  bleeding  from  smaller  vessels  with  serious 
symptoms  might  reasonably  be  dealt  with  by  the  same  means 
now  frequently  employed  for  losses  of  large  quantities  of  blood 
due  to  various  other  causes.  Since  Wooldridge's  original 
paper,  transfusion  has  been  simplified  to  such  an  extent  that 
no  patient  suffering  from  loss  of  blood,  no  matter  what  the 
cause,  should  be  allowed  to  die  without  such  a  simple  measure 
as  here  advocated.     All  that  is  required  is  a  small  cannula  for 


'  Centralblatt  fllr  Chirurgie,  1882,  No.  46,  p.  756. 
'■^  Trans.  Amer.  Surg.  Assoc.  1892,  vol.  x.  p.  219. 
^  Archiv  fiir  klin.  Chir.  1889,  vol.  xxxix.  p.  799. 
"  Ibid.  1880,  vol.  xxx.  p.  2. 
''  New  Yorl'  Med.  Joimi.  1892,  vol.  Iv.,  p.  584. 


PLATE    VIII. 


Fig  15. — Perforating  Ulcers  of  Stomach. — The  two  parts  were  removed  from  the 
same  organ.  The  upper  shows  the  flattened  slightly  depressed  cicatrix  of  a 
large  healed  ulcer,  and  cicatrices  of  smaller  ones.  The  lower  shows  a 
deeply  excavated  ulcer  which  had  caused  death  by  perforation  into  the 
peritoneal  cavity.     (IV.I.M.,  Glas.) 


ULCER  181 

insertion  into  a  vein,  an  indiarubber  tube  about  a  couple 
of  feet  long,  one  end  of  which  is  attached  to  the  cannula,  the 
other  to  the  nozzle  of  the  filler  or  funnel.  A  quantity  of 
so-called  normal  saline  solution  is  taken — that  is,  water 
(sterilised  if  possible)  at  a  temperature  of  from  105°  to  110°  F. 
and  containing  a  teaspoonful  of  common  table  salt  to  a 
pint  of  the  fluid.  This  is  poured  into  the  glass  receptacle 
and  allowed  to  flow  slowly  into  the  vein.  From  one  to  five 
or  six  pints  may  thus  with  perfect  safety  be  passed  into  the 
patient's  circulation,  provided  all  the  little  necessary  surgical 
precautions  are  taken  in  reference  to  treatment  of  the  wound 
and  the  introduction  of  the  fluid.  In  a  case  reported  by 
Dewhurst '  such  a  line  of  treatment  was  entertained,  but  was 
apparently  too  late  in  its  adoption  to  be  of  any  service. 

Mikulicz  ^  reports  a  case  of  obstinate  haemorrhage  which 
was  uncontrollable  by  ordinary  medicinal  measures,  where  he 
performed  lapar atomy,  incised  the  stomach  along  the  anterior 
wall,  and  then  cauterised  the  ulcer  with  the  thermo-cautery. 
Death  occurred  fifty  hours  after  the  operation.  Kiister^  has 
in  two  cases  opened  the  stomach,  cauterised  the  ulcer,  and  per- 
formed gastro-enterostomy.     Both  cases  did  well. 


CHAPTER   XXII 

ULCER  (continued) :  perforation 

3.  Perforation. — As  here  used,  perforation  is  intended  to 
imply  a  more  or  less  direct  communication  between  the  cjivity 
of  the  stomach  and  the  general  peritoneal  cavity.  With  the 
exception  of  sudden  and  severe  haemorrhage  there  is  no  com- 
plication of  gastric  ulcer  more  serious  or  more  difiicult  to 
deal  with.  While  the  accident  is  not  inevitably  a  fatal  one, 
it  is  so  in  the  large  majority  of  cases.  Parsons  "*  carefully 
examined  the  literature  of  the  subject,  and  could  find  recorded 
only  nine  cases  which  presented  symptoms  indicative  of 
perforation  of  a  gastric  ulcer  and  recovered.     Of  these,  three 

'  Lancet,  1892,  vol.  ii.  p.  141. 

^  ArcJiiv  fur  klin.  Chir.  1887,  vol.  xxxvii.  p.  79. 

3  Centralblatt  fiir  Chirurgie,  1894,  No.  51,  p.  1254. 

*  Dublin  Journal  of  the  Medical  Sciences,  1892,  vol.  xciv.  p.  26. 


182  THE   STOMACH 

died  subsequently  from  this  affection  ;  but  in  only  one  of  them 
did  the  post-mortem  examination  seem  to  confirm  the  original 
diagnosis.  This  case  is  reported  by  Hughes,  Eay,  and  Hilton 
in  the  *  Guy's  Hospital  Eeports  '  for  1846.^  The  rapidity  also 
with  which  a  fatal  issue  ensues  is  second  only  to  that  of  exces- 
sive haemorrhage.  In  Fagge's  experience  nearly  all  the  cases 
of  perforating  ulcer  were  fatal  in  less  than  twenty-four  hours. 

The  question  therefore  of  treatment  in  this  particular 
complication  does  not  admit  of  much  time  being  spent  in 
its  consideration.  Whatever  is  to  be  done  will  have  to  be 
done  quickly,  and  experience  so  far  goes  to  prove  that  success 
depends  chiefly  upon  the  shortness  of  the  time  which  is 
allowed  to  intervene  between  the  onset  of  the  acute  symptoms 
and  the  performance  of  the  operation. 

That  the  acute  symptoms  of  perforative  peritonitis  with 
which  the  patient  is  suddenly  struck  down  owe  their  origin  to 
the  rupture  of  a  gastric  ulcer  is  often  purely  conjectural.  As 
pointed  out  by  Treves  ^  in  his  Lettsomian  Lectures  on  Perito- 
nitis, '  All  quite  acute  troubles  within  the  abdomen  commence 
with  the  same  train  of  symjotoms.  .  .  .  Until  many  hours 
have  elapsed  it  is  often  impossible  to  say  whether  a  sudden 
abdominal  crisis  is  due  to  the  perforation  of  a  vermiform 
appendix,  or  to  the  bursting  of  a  pyosalpinx,  or  to  the  stran- 
gulation of  a  loop  of  intestine,  or  to  the  passage  of  a  gall 
stone.'  It  might  be  reasonably  supposed  that  the  previous 
history  of  the  case  would  always  lend  a  sufficient  aid  towards 
the  detection  of  the  true  cause.  Unfortunately  in  a  large 
number  of  these  cases  there  is  no  early  history  of  ulcer ;  the 
patient  has  been  completely  free,  or  almost  so,  from  any 
gastric  disturbance  until  suddenly  seized  with  severe  symptoms. 
The  difficulties  which  the  surgeon  has  to  encounter  in  his 
treatment  are  no  less  than  those  which  the  physician  has  in 
arriving  at  a  correct  diagnosis.  It  is  not  possible  beforehand 
to  localise  the  seat  of  the  perforation,  to  define  its  limits,  or  to 
say  how  it  will  have  to  be  dealt  with  when  discovered ;  neither 
is  it  within  his  power  to  say  whether  the  condition  of  general 
peritonitis  which  has  arisen  is  too  far  advanced  to  be  re- 
covered from. 

'  New  Series,  vol.  iv.  p.  343. 

''  Brit.  Med.  Journ.  1894,  \ol.  i.  p.  455. 


ULCER  183 

In  consideration  of  the  difficulties  therefore  which  exist 
both  in  respect  of  diagnosis  and  treatment,  it  will  be  well  to 
discuss  somewhat  in  detail  various  points  in  connection  with 
both  these  aspects  of  the  question. 

These  cases  may  be  said  to  class  themselves  under  two 
heads.  First  there  are  those  where  the  symptoms  though 
acute  are  not  markedly  so,  and  where  perforation  is  known 
to  have  occurred  on  an  empty  stomach ;  and,  secondly, 
those  where  the  symptoms  from  the  commencement  are  exces- 
sively acute,  and  where  perforation  has  taken  place  during  or 
shortly  after  a  meal.  In  the  latter  class,  the  only  chance  of 
life  rests  in  operation,  and  that  performed  at  the  earliest 
possible  period  of  the  attack.  In  the  former  there  would 
seem  to  be  some  reason  for  raising  the  question  of  delay,  since 
recoveries  without  surgical  interference  have  been  known  to 
occur.  Hall '  records  such  an  instance,  and  refers  to  six 
others.  In  three  of  these  it  was  known  for  certain  that  the 
stomach  was  practically  empty  at  the  time  of  the  perforation, 
and  in  the  other  three  the  narrative  of  each  case  suggests 
that  a  similar  condition  existed. 

There  are  two  other  conditions  besides  those  which  have 
direct  reference  to  the  state  of  the  stomach  at  the  time  of 
perforation  which  should  have  some  weight  in  determining 
the  advisability  or  not  of  immediate  operative  interference ; 
these  are,  the  position  of  the  patient  at  the  time  of  the  acci- 
dent, and  a  history  of  previous  attacks  of  pain.  In  the 
former  instance  a  patient  at  active  work  in  the  erect  attitude 
is  more  likely  to  have  a  large  extravasation  of  the  contents  of 
the  stomach  into  the  peritoneal  cavity  than  one  who  is  seized 
at  night  in  the  recumbent  position.  In  the  latter  instance 
a  history  of  periodical  attacks  of  pain  will  probably  indicate 
attacks  of  local  peritonitis,  and  as  a  consequence  the  existence 
of  adhesions.  In  such  cases  the  perforation  may  not  prove  of 
the  same  magnitude  as  where  no  adhesion  exists. 

The  purely  operative  aspects  of  the  question  concern  first 
the  most  suitable  place  to  open  the  abdomen,  and  second,  the 
treatment  of  the  gastric  lesion. 

To  expose  the  stomach  the  best  incision  is  one  carried 
downwards  from  just  below  the  ribs  for  about  three  or  four 
'  Brit.  Med.  Journ.  1892,  vol.  i.  p.  G4. 


184  THE   STOMACH 

inches  and  slightly  to  the  left  of  the  median  line  ;  this  can  be 
subsequently  enlarged  in  the  direction  required.  To  flush 
and  drain  the  peritoneal  cavity  the  best  incision  is  one  carried 
through  the  parietes  in  the  me^lian  line  below  the  umbilicus. 
To  wash  out  the  abdominal  cavity  and  leave  a  leaking  orifice 
would  prove  almost  as  fatal  as  to  close  the  perforation  and 
leave  some  of  the  escaped  contents  of  the  stomach  in  the 
dependent  parts  of  the  peritoneal  cavity.  The  wisest  course 
of  procedure  would  therefore  seem  to  be  to  make  first  the 
incision  above  the  umbilicus  so  as  to  expose  and  examine  the 
stomach  ;  then,  if  the  leakage  has  been  considerable  and  it 
is  not  found  possible  to  satisfactorily  flush  and  remove  all 
extravasated  material,  to  make  a  second  opening  below  the 
umbilicus  through  which  perfectly  efficient  drainage  of  the 
peritoneal  cavity  can  be  established.  While  the  very  fatal 
nature  of  these  cases,  when  left  alone,  admits  of  considerable 
risk  being  run  in  the  way  of  operative  treatment,  it  seems 
better  to  operate  by  two  abdominal  incisions  than  to  adopt 
the  severer  measure  of  laving  the  abdomen  open  from  sym- 
j)hysi8  to  xiphoid  cartilage,  as  performed  in  one  case  by 
Mikulicz,  The  extent  of  the  incision  is  not,  however,  so  vital 
as  the  efficient  cleansing  of  the  peritoneal  cavity,  and  must 
be  considered  therefore  subservient  to  ail  that  concerns  the 
latter. 

Assuming  that  the  stomach  is  exposed  by  the  upper 
incision,  a  careful  search  is  made  for  the  seat  of  perforation. 
This  may  be  detected  either  by  the  existence  of  adhesions 
binding  down  the  floor  of  the  ulcer  to  neighbouring  parts, 
or  by  the  thickening  in  the  wall  of  the  stomach  immediately 
around  the  ulcer  and  seat  of  perforation.  The  locality  of 
the  lesion  once  determined,  an  endeavour  should  be  made 
to  bring  the  affected  portion  of  the  stomach  up  to  the 
abdominal  incision.  As  likely  as  not  this  will  be  found 
impossible  either  from  the  position  of  the  ulcer  or  from  the 
adhesions  which  it  has  contracted  to  other  parts.  If  freer 
access  to  the  part  appears  desirable,  and  this  can  be  attained 
l\y  a  transverse  incision,  the  rectus  should  be  divided,  the 
branches  of  the  internal  mammary  being  secured  as  they  are 
severed.  Before  proceeding  further  to  deal  with  the  perfora- 
tion, an  endeavour  should  be  made  to  ascertain  the  condition 


ULCER  18;-, 

of  the  stomach  with  regard  to  its  contents.  If  perforation 
has  taken  place  during  or  shortly  after  a  heavy  meal,  it  will 
be  wise  to  relieve  the  stomach  of  its  load.  This  may  be  done 
either  through  the  perforation  itself,  or  through  the  oesopha- 
gus by  means  of  a  tube.  The  selection  of  the  method  will 
depend  upon  the  extent  to  which  the  perforation  itself  can  be 
manipulated.  Any  further  extravasation  into  the  peritoneal 
cavity  should  be  carefully  avoided. 

In  dealing  with  the  perforation  four  alternatives  are  open 
for  adoption  according  to  circumstances :  (1)  Excision  of  the 
ulcer,  including  the  seat  of  perforation,  and  union  of  the 
edges  of  the  wound  in  the  usual  way ;  (2)  simple  suture  of  the 
perforation  by  Lembert's  method  ;  (3)  union  of  the  perforated 
gastric  area  with  the  parietal  wound ;  (4)  open  drainage. 

(1)  Excision  of  the  perforated  ulcer. — While  this  is  the 
most  radical  procedure,  and  theoretically  the  most  suggestive, 
it  is  frequently  the  least  practicable.  If  not  the  position 
of  the  ulcer,  its  size  and  amount  of  surrounding  indura- 
tion may  render  it  quite  inadvisable  to  attempt  so  large 
an  excision  of  a  part  of  the  stomach.  Where,  however,  ex- 
cision does  seem  feasible,  there  can  be  little  doubt  that  it  is 
ideally  the  best  treatment.  Jowers  succeeded  in  the  case  of 
a  woman  aged  24  years.  The  ulcer  was  situated  near  the 
cardiac  end,  and  was  excised  by  means  of  scissors.  Dalziel 
similarly  succeeded  in  a  woman  aged  26. 

(2)  Simjile  suture  of  the  jyerforatiou  by  Lemherfs  metliod. — 
This  method,  which  has  strongly  in  its  support  the  fact  that 
it  has  several  times  been  successfully  accomplished,  consists 
in  closing  the  opening  by  suture  ;  that  is  to  say,  the  stomach  is 
picked  up  in  a  fold  on  each  side  of  the  ulcer  and  united  over 
it  by  a  few  Lembert  sutures — the  ulcer,  as  it  were,  being 
tucked  in.  Gilford  reports  having  successfully  adopted  this 
method.  The  patient  died  thirty-one  days  after  the  operation 
from  septicaemia.  liriege  also  records  a  success.  He  treated 
his  patient  seventeen  hours  after  the  acute  symptoms  began. 
The  patient  did  well  at  first,  but  after  about  five  weeks  an 
empyema  developed  in  the  left  pleural  cavity.  This  was  opened, 
and  the  patient  made  a  perfect  recovery.  Morse  read  a  paper 
before  the  lloyal  Medico-Chirurgical  Society  of  London  on  a 
case  upon  which  he  had  successfully  operated  five  hours  after 


186  THE    STOxMACII 

the  onset  of  the  acute  symptoms.  The  perforation  was  closed 
with  Lembert  stitches,  the  peritoneal  cavity  freely  flushed,  and 
the  patient  three  weeks  afterwards  was  quite  well.  Maclaren 
related  a  successful  case  at  a  meeting  of  the  British  Medical 
Association  at  Bristol  in  1894.  The  patient  was  a  girl  aged 
14  years,  and  the  operation  was  performed  nine  hours  after 
perforation.  T.  Holmes,'  in  the  second  of  his  Hunterian 
Lectures,  quotes  a  case  successfully  treated  by  Bennett.  An 
opening  about  the  size  of  a  little  finger  was  found  in  the 
posterior  wall  of  the  stomach.  It  was  stitched  up.  The 
operation  was  performed  about  nine  and  a  half  hours  after 
the  onset  of  the  symptoms.  A  very  successful  result  was 
obtained  in  a  case  reported  by  Nicholson.  Laparotomy  was 
performed  three  hours  after  perforation.  The  ulcer  with  the 
perforation  was  found  on  the  anterior  and  upper  surface, 
very  near  the  entrance  of  the  oesophagus.  Suture  was 
performed.  Recovery  set  in  immediately.  Lundie  showed 
a  patient  at  the  Edinburgh  Medico-Chirurgical  Society  upon 
whom  he  had  successfully  operated  ten  hours  after  the  first 
onset  of  the  acute  symptoms.  The  ulcer  was  stitched  up, 
and  there  were  already  signs  of  acute  general  peritonitis. 
L.  A.  Dunn  succeeded  in  closing  a  perforation  one-third 
by  a  quarter  of  an  inch,  situated  in  the  anterior  wall  of 
the  stomach  near  the  pylorus.  The  patient  ultimately  made 
a  rapid  recovery.  J.  H.  Walters  was  similarly  successful 
in  closing  a  perforation  thirteen  and  a  half  hours  after  the 
onset  of  symptoms.  In  a  case  reported  by  Bilton  Pollard, 
the  ulcer  was  situated  near  the  cardiac  end  of  the  stomach 
and  on  the  anterior  surface,  about  an  inch  and  a  half  from 
the  greater  curvature.  In  order  to  properly  expose  the 
part  the  parietal  incision  had  to  be  enlarged  by  a  transverse 
one  dividing  the  rectus  muscle.  The  perforation  measured 
half  by  one-third  of  an  inch,  and  the  stomach  wall  for  about 
two  inches  around  was  much  indurated.  The  orifice  was 
stitched  up  seven  and  a  half  hours  after  the  perforation.  The 
patient  made  an  excellent  recovery.  W.  J.  Maurice  operated  in 
a  case  nine  hours  after  perforation ;  a  small  opening  was  found 
on  the  anterior  surface  of  the  stomach,  it  was  closed  by 
two  rows  of  Lemberts,  and  the  patient  made  a  good  recovery, 
H.  Morris  operated  on  a  case  four  hours  after  perforation. 

'  Brit.  Med.  Journ.  1894,  vol.  ii.  p.  863. 


ULCER  187 

The  aperture  was  found  on  tlie  anterior  aspect  of  tlie  stomach, 
close  to  the  pylorus  and  near  the  greater  curvature.  The 
patient  recovered. 

(3)  Stitching  the  seat  of  iierforation  to  the  abdominal 
incision. — This  method  entails  the  temporary  formation  of 
a  gastric  fistula.  Haward  communicated  a  case  to  the 
Clinical  Society  of  London  where  sach  a  method  was  adopted. 
The  patient,  a  woman  aged  26,  was  admitted  into  the 
hospital  in  a  state  of  collapse  due  to  the  perforation  of  a 
gastric  ulcer.  She  was  operated  upon  fourteen  hours  after 
the  onset  of  the  acute  symptoms.  An  ulcer,  the  perforated 
centre  of  which  would  admit  a  finger,  was  found  opening  into 
the  general  peritoneal  cavity.  Owing  to  the  great  infiltration 
and  thickening  of  the  gastric  wall,  excision  could  not  he  per- 
formed. The  stomach  was  therefore  sutured  to  the  ahdominal 
wall,  and  the  margin  of  the  ulcer  to  the  edge  of  the  incision. 
A  drainage  tube  was  inserted  into  the  stomach,  the  peritoneal 
cavity  washed  out,  and  the  rest  of  the  wound  closed.  The 
patient  died  six  weeks  afterwards  from  purulent  consolidation 
of  the  bases  of  both  lungs.  Parsons  also  records  a  partially 
successful  case,  which  is  more  fully  described  as  Case  L.  at 
the  conclusion  of  this  chapter, 

(4)  Open  drainage. — Whether  it  is  possible  to  bring  the 
perforation  up  to  the  abdominal  incision  for  efiicient  union 
of  the  parts  will  naturally  depend  upon  the  locality  of  the 
ulcer  and  the  amount  of  existing  adhesions.  It  is  quite  pos- 
sible that  the  surgeon  may  find  that  he  is  unable  to  carry  out 
any  one  of  the  measures  above  described.  In  such  a  case  his 
only  resort  is  to  free  drainage.  A  tube  must  be  passed  down 
to  the  perforation  and  secured  there,  so  that  any  further 
extravasation  is  conveyed  out  through  the  abdominal  wound. 
This  method  was  successfully  carried  out  by  Paul,  who 
tied  a  glass  tube  into  the  front  wall  of  the  stomach.  The 
ulcer  was  situated  at  the  cardiac  end  of  the  lesser  curvature. 
In  a  case  reported  by  J.  W.  Taylor,'  the  stomach  was  left  alone 
and  drainage  trusted  to.  This  case  is  interesting  also  from  the 
extremely  collapsed  condition  of  the  patient  at  the  time  of 
operation,  which  was  performed  twenty- four  hours  after  the 
acute  symptoms  first  showed  themselves.  The  pulse  was 
indistinguishable  and  the  patient  almost  moribund.     Eapid 

'  Blrmingliam  Med.  Ecviciv,  1888,  vol.  i.  p.  159. 


188 


THE   STOMACH 


improvement  took  place  immediately  after  the  operation,  and 
the  patient  died  some  weeks  later  from  acute  obstruction. 
Silcock,  in  operating  upon  a  case,  found  a  wide  band  of  fibri- 
nous adhesions  binding  the  anterior  surface  of  the  stomach  to 
the  under  surface  of  the  left  lobe  of  the  liver.  The  adhesions 
were  left  alone  and  a'  drainage  tube  conducted  down  to  the 
part.     The  patient  made  an  uninterrupted  recovery. 

For  the  various  references  in  connection  with  the  cases 
quoted  above,  see  the  following  table  : 

Cases  of  Perforation  of  Gastric  Ulcer  successfully  treated  by  Operation 

since  1891 


Name  of 
Operator 


Sex  and 
Age 


Situation  and 
Size  of  Per- 
foration 


Interval  between 

0ijset(  f 

symptoms  and 

opeiatiou 


Treatment  of 

Peritonciil 

(Javity 


(1)  BY  EXCISION 


R.  F.  Jowers 


T.  K.  Dalziel 


Posterior  snr- 
face,  near  car- 
diac end. 
Size  of  tliree- 
pemiy  piece 

Anterior  sur- 
face close  to 
pylorus.  I 
by  i  inch 


6  hours 


5i 


(2)  BY  SIMPLE  SUTURE 


Kriege     . 

M.  41 

H.  Gilford 

P.  20 

T.  H.  Morse    . 

F.20 

R.  Maclareu    . 

F.  14 

R.  H.  B.  Nichol- 

F. 32 

son 

B.  Pollard 

F.  18 

W.  H.  Bennett 

F.  41 

R.  A.  Lundie   . 

F.,  young 

Anterior   wall, 

3  cm.  from 
cardia.  Size 
of  a  pea 

Posterior  sur- 
face, neai'  car- 
diac orifice. 
Perforation 
admitted  fin- 
ger 

Anterior  sur- 
face, near 
cardiac  end 

Anterior  sur- 
face, 2  inches 
from  cardiac 
end 

Anterior  and 
upper  sur- 
face, near 
cardiac  end 

Anterior     sur- 
face, IJ  inch 
from  greater 
curvature. 
Perforation 

4  by  J  inch 
Posterior    sur- 
face. Adicit- 
tcd   point  of 
little  finger 

Anterior  sur- 
face. Eyelet 
hole  in  a  boot 


17  hours 


9i   „ 


10 


Flushed     with 
boiled  water 


Sponging  and 
use  of  asep- 
tic water 


Wiped  out  with 
gauze.  Gauze 
drainage  in- 
seiteil 

Fhislied  with 
water  and 
c  r  e  0  1  i  n  . 
Drainage 


Flushed 


Flushed    with 
boiled  water 


Flushed  with 
warm  water. 
Sponged  dry 


Peritonitis  pre- 
sent. Flushed 
with  warm 
water 

Peritonitis  pre- 
sent. Flushed 


Lancet,   1895, 
i.  544 


Qla  (low  Med. 
Journ.  1896, 
xlv.  302 


Berl.     Klin. 
Wochcn. 
18a2,  1280 

Brit.  MM. 
Journ.  1893, 
i.  944 


Trans.  Med.- 
C/iir.  iS'oc. 
Land.  1894, 
Ixxvii.  187 

Brit.  Med. 
Journ.  1894, 
ii.  863 

Ibid.  982 


Ibid.       1895, 
ii.  14 


ULCER 


189 


Situation  anil 

1 

Int(rval  between 

Treatment  of 

N:imo  of 

Sex  and 

Kizu  of  Per- 

onset of 

Peritoneal 

Reference 

OiiLTiitur 

Age 

foration 

symptoms  and 
operation 

Cavity 

( 

2)   BY   SIMPLE 

SVTUnH— continued 

J.  H.  Walters  . 

F.  20 

Anterior     sur- 

13i hours 

Flushed     with 

Lancf/,   1895, 

face,  towards 

weak  bnracic 

i.  484 

lesser  enrva- 

solution 

tnre,  Sinelies 

from  eardiac 

oriliee 

W.  J.  Miinricc 

P.  19 

Anterior     sur- 
face,       near 
cardiac  end 

9     „ 

Flushed     with 
water 

Ilml  ii.  981 

H.  Moriis 

F.  24 

Anterior     sur- 
face, close  to 
pylo"us    and 
greater  cur- 
vat  ure.    No. 
12  catheter 

4     „ 

Flushed  with  1 
in    4U0    car- 
bolic      solu- 
tion.   Pelvis 
sponged  out 

Ibid.  ii.  1573 

L.  A.  Dunn 

F.  15 

Anterior     sur- 

2J days 

Flushed     with 

Trann.     Clin. 

face,        near 

wai-m  boiled 

.S'oc.      Zo)id. 

pjlorus.        J 

water 

1895,  xxviii. 

by  I  incli 

2U4 

f3)  BY 

STITCHING   PERFORATION    TO  PARIETES 

W.  Hawaril      . 

F.  26 

Threepenny 
piece 

14  Iiours 

Flushed 

Ihid.  1893, 
xxvi.  179 

A.  II.  Parsons . 

F. 

( 

Anterior     sur- 
face       near 
cardiac    end 
and       lesser 
curvature 

1)  BY   DRAIN  A 

9     „ 
CJE   AND   STUF 

Flushed 
FIXG 

Dub.  Journ. 
Mf'd.  Sci. 
1892,  xciv. 
29 

F.  Paul    . 

F.  31 

'  In  an  almost 

9  hours 

Drainage  tube 

lirit.        Med. 

inacces-ible 

into       front 

Jonrn.  1895, 

position ' 

wall  of  sto- 
mach for  15 
days.       Fis- 
tula    closed 
14  days  later 

i.  759 

A.  Q.  Silcoek  . 

F.  24 

A  few  hours 

Trans.  Clin. 
8oc.  Loud. 
1S<95,  xxviii. 
217 

C.  J.  Parker    . 

F.  25 

Perforation  oc- 

Flushed,    and 

Annals        of 

curred  at  the 

perforated 

Surgery, 

time  of  01  e- 

area  stufled 

1896,    xxiii. 

ration 

735 

The  last  part  of  the  operation,  after  the  perforation  haa 
been  dealt  with,  concerns  the  efficient  washing  out  and  drain- 
ing of  the  peritoneal  cavity.  It  has  already  been  indicated 
that  to  accomplish  this  with  the  amount  of  certainty  requisite 
for  a  successful  result,  it  may  be  necessary  either  to  enlarge 
the  incision  downwards  or  to  make  a  second  incision  below 
the  umbilicus.  If  on  opening  the  abdomen  at  the  earlier  stage 
particles  of  fat  or  food  are  seen  to  escape  from  the  upper 
incision,  it  may  almost  certainly  be  concluded  that  some  of 
this  same  material  will  have  found  its  way  down  into  the 


190  THE    STOMACH 

most  dependent  parts  of  the  abdominal  cavity ;  and  to  ensure 
its  complete  removal  from  the  pelvis,  a  second  incision 
or  an  extension  of  the  firat  must  be  made.  To  flush  the 
peritoneal  cavity,  quantities  of  boiled  water  reduced  to  the 
requisite  temperature  of  about  100°  F.  should  be  poured  in, 
and  to  secure  the  free  irrigation  of  all  parts,  the  coils  of 
intestine  should  be  gently  moved  about  by  the  fingers  of  one 
hand.  Experience  has  quite  sufficiently  proved  the  needless- 
ness  of  using  any  weak  antiseptic  reagent  when  warm  sterilised 
water  is  obtainable.  And  for  all  the  weak  antiseptic  properties 
that  such  diluted  solutions  of  these  reagents  possess,  it  is  more 
than  probable  that  plenty  of  clean  warm  water  answers  the 
purpose  perfectly.  That  the  introduction  of  antiseptics  with- 
in the  peritoneal  cavity  is  not  without  danger  has  been 
amply  proved.  In  one  of  the  cases  already  quoted,  the  intro- 
duction of  creolin  into  tlie  flushing  fluid  caused  symptoms  of 
poisoning. 

Finally,  the  insertion  of  one  or  more  drainage  tubes  well 
into  the  pelvis  should  always  be  adopted  where  the  leakage 
from  the  stomach  has  been  marked.  FaiHng,  however,  any 
such  obvious  extravasation,  the  wound  in  the  abdominal  parietes 
should  be  completely  closed. 

The  after  treatment  in  these  cases  is  of  some  moment. 
The  stom.ach  requires  to  be  given  as  much  rest  as  possible ; 
and  although  in  some  of  the  successful  cases  something  has 
been  administered  by  the  mouth  within  twenty- four  hours  of 
the  operation,  it  is  safer  that  nourishment  should  for  the  first 
few  days  be  administered  by  nutrient  enemata,  and  nothing 
more  than  a  little  ice  given  by  the  mouth  if  so  required. 
These  patients  fortunately  are  not  so  reduced  that  they  can- 
not stand  a  comparatively  prolonged  period  of  abstinence 
from  food  by  the  mouth.  No  haste  therefore  should  be 
exercised  in  returning  to  the  natural  method  of  nutrition. 

Case  L. Ferf oration  of  gastric  ulcer :  laparotomy  :  suture  of 

perforation.  Recovery. 
A  young  woman  aged  24  years  had  enjoyed  good  health  until  two 
years  ago,  when  she  became  subject  to  indigestion,  which,  however,  had 
only  given  trouble  during  the  preceding  six  months.  The  chief  symptom 
was  epigastric  pain  very  soon  after  taking  food  and  lasting  for  some  two 
hours.  During  the  previous  three  months  there  had  also  been  sickness 
after  food,  sometimes  on  several  successive  days,  and  for  the  last  six  or 
ei"lat  weeks  she  had  not  toxxched  meat  or  potatoes  on  accoixnt  of  the  pain 


ULCER  191 

which  followed.  On  one  occasion,  some  four  montlis  previously,  she 
vomited  a  small  quantity  of  dark  blood.  The  patient  was  in  her  usual 
health  on  the  morning  of  the  10th  inst.  and  took  boiled  haddock  at  her 
midday  meal  (12.30).  At  2.30  p.m.,  as  she  was  hurrying  up  stairs,  she  was 
suddenly  seized  by  a  strong  '  drawing  '  pain  in  the  lower  abdomen.  TJiis 
rapidly  increased  in  area  and  intensity,  and  by  the  time  she  reached  the 
hospital,  an  hour  later,  had  spread  over  the  whole  abdomen.  She 
managed  to  walk  to  the  hospital,  about  a  quarter  of  a  mile,  but  was 
doubled  up  with  pain  and  felt  faint.  There  was  no  vomiting.  Physical 
examination  of  the  abdomen  showed  slight  uniform  distension ;  the 
parietes  were  flaccid,  and  gentle  palpation  could  be  borne  without  pain. 
The  percussion  note  everywhere  was  tympanitic,  and  the  liver  duhiess 
was  completely  obliterated.  An  hour  later,  the  face,  which  at  first  was 
flushed  and  comparatively  normal  in  appearance,  became  anxious  and 
somewhat  pinched  ;  the  abdomen  became  rigid  and  acutely  tender.  Dis- 
tension also  increased. 

Operation. — Four  hours  after  the  onset  of  the  syinptoms  laparotomy 
was  performed.  A  median  incision  four  inches  long  (subsequently  en- 
larged) was  carried  from  the  costal  angle  towards  the  lunbilicua.  On 
opening  the  peritoneal  cavity  offensive  gas  escaped.  On  drawing  the 
stomach  tip  into  the  wound,  a  perforation  the  size  of  a  No.  12  catheter 
was  brought  into  view.  It  was  situated  close  to  the  pylorus  on  the 
anterior  surface,  near  the  greater  curvature.  The  ulcerated  portion  of 
the  stomach  was  invaginated  by  means  of  eight  Lembert  sutures  of 
No.  2  silk,  a  second  row  of  sutures  being  placed  more  siiperficially  to 
strengthen  them.  The  peritoneum  was  thoroughly  irrigated  with 
a  1  in  400  carbolic  solution  at  105°  F.,  and  the  pelvis  sponged  out  as 
dry  as  possible.  The  various  pei-itoneal  pouches  were  sirailarly  dealt 
with.  Much  lymph  was  removed  from  the  surface  of  the  liver.  The 
abdominal  wound  was  closed  with  nine  thick  silk  sutures,  and  the  usual 
dressing  applied.  For  the  first  three  days  nothing  was  given  by  the 
mouth  except  a  little  hot  water,  but  on  the  third  day  two  teaspoonfuls  of 
hot  tea  and  milk  were  given  every  hour.  Afterwards  arrowroot  was  given, 
but  for  the  first  week  nourishment  was  mostly  by  nutrient  enemata. 
About  four  weeks  after  the  operation  she  left  the  hospital  cured.  (W. 
Pasteur  and  Henry  Morris,  '  Lancet,'  1895,  vol.  ii.  p.  1573.) 

Case  LI. — Perforation  of  gastric  ulcer:  laparotomy  and  fixation  of 
the  gastric  opening  to  the  edge  of  the  parietal  incision.  Death  on 
the  sixth  day. 

During  the  two  years  immediately  preceding  the  symptoms  of  perfora- 
tion, the  patient,  a  woman,  had  been  in  the  infirmary  three  or  four 
times  suffering  from  attacks  of  severe  pain  in  the  stomach.  These  attacks 
were  not  very  closely  related  to  meal  times,  as  they  occurred  sometimes 
before,  sometimes  after,  and  often  quite  independently  of  partaking  of 
food.  She  never  vomited  any  blood.  The  existence  of  an  nicer  of  tlie 
stomach  was  entertained,  but  with  no  great  degree  of  certainty.  After 
four  days  of  more  acute  pain  than  usual,  during  which  time  she  continued 
at  her  work,  bat  could   take  but  little  food,   she  was  suddenly-  seized 


192  THE   STOMACH 

a  little  after  ei.sjht  o'clock  on  the  morning  of  December  21  with  most 
violent  pain.  When  seen  at  9.30  a.m.,  she  referred  the  pain  to  the  left 
hypochondriac  region.  The  pnlse  was  100  per  minute ;  resj)irations  were 
tolerably  deep.  An  examination  of  the  region  to  which  the  pain  was 
referred  failed  to  detect  anything  abnormal.  At  11  a.m.  the  collapse  was 
much  more  marked,  the  pulse  110,  finger  nails  were  blue,  face  was  drawn 
and  anxious,  and  the  patient  rather  cold  in  spite  of  various  external  warm 
applications.  On  examination  the  area  of  hepatic  dulness  was  found  to  be 
diminished  and  the  note  over  the  hepatic  region  abnormally  tympanitic. 
At  four  o'clock  laparotomy  was  performed.  By  this  time  the  pulse  had 
increased  somewhat  in  frequency,  but  otherwise  there  was  no  marked 
change  in  her  condition.  Immediately  the  peritoneal  cavity  was  incised 
an  escape  of  gas  took  place,  thus  confirming  the  fact  of  perforation,  the 
site  of  which  was  found  to  be  the  anterior  wall  of  the  stomach  in  its 
lesser  curvature  near  its  junction  with  the  oesophagus.  The  wall  of  the 
stomach  all  round  the  perforation  was  thickened,  swollen,  and  so  soft  that 
sutures  at  once  cut  through  it.  The  external  circumference  of  the  stomach 
at  this  part  appeared  so  small  that  no  hope  could  be  entertained  of 
excising  the  ulcer  completely  without  leaving  too  great  a  constriction. 
The  stomach  was  therefore  drawn  up  by  stitches  to  the  edges  of  the 
abdominal  wound  and  carefully  sutured  there.  The  peritoneal  cavity  was 
then  flushed  out  and  the  lower  part  of  the  abdominal  incision  closed, 
leaving  a  gastric  fistula.  The  patient  rallied  well  from  the  operation,  and 
made  satisfactory  progress  until  Wednesday — two  days  after  the  opera- 
tion— when  a  change  for  the  worse  set  in,  and  she  died  on  Sunday,  just 
six  days  after  operative  interference.  (Parsons,  '  Dublin  Journal  of  the 
Medical  Sciences,'  1892,  vol.  xciv.  p.  29.) 


CHAPTER   XXIII 

ULCER  {continued):  formation  of  abscess;  fistulous  com- 
munications ;  external  adhesions  ;  internal  contraction  ; 
pyloric  stenosis 

4.  Formation  of  purulent  collections  and  other  septic 
changes. — As  a  sequel  to  gastric  ulcer,  the  formation  of  an 
abscess  is  by  no  means  an  infrequent  occurrence.  In  some 
instances  the  septic  mischief  which  arises  does  not  take  the 
form  of  an  abscess.  Thus  pericarditis,  pleurisy,  empyema, 
and  pneumonia  are  occasionally  met  with.  Whatever  may 
be  the  septic  nature  of  the  more  distant  complications, 
they  are  usually  found  to  be  secondary  to  some  primary 
formation  of  pus  in  the  immediate  neighbourhood  of  the 
ulcer.     It  would  seem  to  be  rare  for  any  septic  absorption  to 


ULCER  193 

take  place  from  the  ulcer  itself,  independent  of  the  first  pro- 
duction of  inflammatory  adhesions  and  other  mischief  at 
the  floor  of  the  ulcer.  The  intrathoracic  complications  are 
almost  always  due  to  the  pre-existence  of  a  so-called  suh- 
diaphragmatic  abscess.  Out  of  twenty-eight  cases  collected  by 
Dickinson  '  of  this  latter  complication,  eighteen  manifested 
some  form  of  intrathoracic  trouble. 

The  interest  of  these  cases  to  the  surgeon  centres  ia  the 
situation  and  extent  of  the  purulent  collection.  While  it  is 
far  from  being  always  possible  to  state  that  a  certain  intra- 
abdominal abscess  situated  in  the  upper  half  of  the  abdomen 
owes  its  origin  to  a  gastric  ulcer,  a  very  safe  assumption  may 
be  made  that  such  is  the  cause  when  a  previous  history  exists 
of  symptoms  indicative  of  ulceration.  I'he  abscess,  when 
aspirated  or  opened,  is  frequently  found  to  have  fetid  and 
gaseous  contents. 

Suppuration  commences  as  a  rule  in  direct  connection 
with  the  ulcer.  Hence  it  often  happens  that  when  the  ulcer  is 
situated  on  the  posterior  aspect  of  the  stomach,  a  considerable 
collection  of  pus  takes  place  before  there  is  any  external  mani- 
festation of  it.  Again,  it  sometimes  happens  that  the  fulness 
which  eventually  manifests  itself  in  the  abdominal  parietes 
does  not  present  the  dull  sound  indicative  of  a  collection  of 
fluid,  but  a  tympanitic  note  due  to  the  gas  which  the  cavity 
contains.  In  some  instances  the  pus  does  not  collect  to  any 
extent  in  the  immediate  neighbourhood  of  the  ulcer,  but 
burrows  to  a  distant  part  and  then  creates  for  itself  a  cavity. 
In  a  case  reported  by  West,^  an  abscess  situated  in  the  left  loin 
was  found  to  extend  into  the  pelvis  and  upwards  to  the 
diaphragm  and  under  the  left  lobe  of  the  liver  to  the  stomach. 
Here  the  stomach  and  the  liver  were  found  adherent,  and  a 
perforation  was  discovered  the  size  of  a  threepenny  piece. 

In  those  cases  where  there  is  pylephlebitis  with  multiple 
abscesses  in  the  liver  and  elsewhere,  and  specially  such  as 
have  purulent  collections  in  distant  parts,  like  the  parotid, 
the  condition  must  be  considered  pyemic  in  character. 

One  of  the  most  interesting  forms  of  abscess  dependent 
upon  gastric  ulcer  is  the  so-called  subphrenic  or  subdiaphrag- 
matic.     Dickinson,  following  the  nomenclature  of  Leyden, 

'  Brit.  Med.  Journ.  1894,  vol.  i.p.  234,  ^  jud  1803,  vol.  i.  p.  731. 

0 


194  THE    STOMACH 

uses  the  term  subphrenic  pyo-pneumothorax,  on  account  of 
the  collection  of  pus  and  gas  not  being  strictly  cf  the  nature 
of  an  abscess,  but  a  collection  of  fluid  bounded  by  the  peritoneal 
walls.  The  foul  gas  and  pus  which  constitute  the  contents  of 
these  collections  may  be  found  anywhere  beneath  the  dia- 
phragm and  between-  it  and  the  liver.  The  more  usual 
locality  is  the  left  hypochondriac  region.  When  the  cavity 
or  collection  of  fluid  and  gas  has  reached  a  sufficient  size,  a 
fulness  presents  itself  in  the  epigastrium,  and  on  percussion  a 
tympanitic  note  maybe  heard  over  the  swelling  and  extending 
either  to  the  right  or  the  left. 

The  constitutional  symptoms  which  may  be  manifested  as 
the  result  of  a  localised  collection  of  pus  vary  considerably. 
In  some  cases  the  onset  of  the  symptoms  is  acute,  while  in 
others  there  is  but  little  disturbance  of  the  patient's  general 
condition  throughout  the  course  of  abscess  formation.  In  one 
of  Dickinson's  recorded  cases  the  patient  had  been  suffering 
for  three  weeks  before  admission  to  the  hospital,  from  pain- 
fulness  and  increasing  prominence  of  the  upper  ab^lomen.  A 
week  before  admission  he  was  attacked  with  severe  pain 
like  colic,  with  which  *  he  was  doubled  up  for  two  hours.'  In 
addition  there  was  much  sweating  coupled  with  feverishness, 
but  no  rigor. 

Localised  pain  with  feverishness  occurring  in  cases  known 
to  have  previously  exhibited  unmistakable  symptoms  of  gastric 
ulcer  should  always  awaken  a  suspicion  of  some  active  septic 
mischief  taking  place.  The  svmptoms  associated  with  abscess 
formation  sometimes  mislead  by  resembling  more  strongly 
symptoms  usually  associated  with  inflammation  elsewhere. 
Thus  two  cases  of  perforating  ulcer  with  subdiaphragmatic 
abscess  are  reported  by  Salter  and  Dickinson,^  in  neither  of 
which  was  a  correct  diagnosis  made.  In  one  the  symptoms 
pointed  to  its  being  a  case  of  pericarditis,  and  in  the  other 
to  one  of  pneumothorax.  Both  patients  died,  but  in  neither 
case  were  the  conditions  found,  which  were  supposed  to  exist 
during  life. 

The  treatment  of  these  cases  consists  in  giving  a  free  exit 
to  the  pus  wherever  located.  A  free  incision  may  always  be 
made  when  the  collection  of  pus  has  increased  to  the  extent 
of  causing  a  prominence  on  some  part  of  the  abdominal  surface. 

'  Lancet,  1891,  vol.  i.  p.  541. 


UJ.CKU  ]9o 

Adhesions  will  have  been  contracted  between  the  aljscess  cavity 
and  the  abdominal  parietes,  so  that,  provided  the  incision  is 
kept  within  a  reasonable  length,  the  danger  of  opening  the 
general  peritoneal  cavity  is  remote.  A  large-sized  drainage 
tube  should  be  inserted  and  retained,  and  the  abscess  cavity 
freely  irrigated  with  some  antiseptic.  The  extreme  foetor  of 
the  pus  induced  me  on  one  occasion,  when  operating  upon  a 
case  of  this  class,  to  make  a  counter  opening,  with  the  object 
of  more  freely  draining  the  cavity.  In  doing  so,  however,  I 
unfortunately  opened  the  lower  part  of  the  pleural  space,  and 
had  subsequently  to  deal  with  a  pyo-pneumothorax.  I  should 
not  be  induced  again  to  attempt  to  drain  more  freely  than  can 
be  perfectly  well  accomplished  through  a  single  opening  and 
a  large  drainage  tube.  One  can  always  be  sure  that  where  the 
abscess  projects  most  prominently,  there  the  adhesions  will  be 
most  secure.  And  while  in  my  case  the  finger  inserted  within 
the  abscess  cavity  seemed  to  impinge  directly  upon  the  skin 
wall  at  another  point  on  the  body  surface,  still,  as  I  unfortu- 
nately learnt,  there  proved  to  be  no  proper  security  against  the 
infection  of  other  parts. 

Provided  there  are  no  other  complications  of  any  gravity, 
the  result  of  opening  and  draining  these  foetid  collections  of 
pus  is  usually  good.  The  cavity  gradually  contracts  and  finally 
becomes  obliterated. 

Case  LII. — Gastric  ulcer  mith  formation  of  subphrenic  abscess  :  opera- 
tion :  recovery.  Death  subsequently  from  septicceniia. 
M.  McL.,  aged  27,  a  housemaid,  was  admitted  on  t^uly  18,  1898,  under 
the  care  of  Dr.  Whipham.  There  was  a  history  of  old  anaemia  and  dys- 
pepsia. Fourteen  days  before  admission  she  had  been  attacked  by  sudden 
severe  pain  at  the  epigastrium  with  vomiting,  and  a  week  later  by  sym- 
ptoms of  pleurisy  on  the  left  side.  On  admission  a  subphrenic  abscess  in 
connection  with  a  gastric  ulcer  was  diagnosed,  there  being  a  tympanitic 
prominence  in  the  epigastrium,  the  tympanitic  note  extending  to  the  left 
and  upwards  as  high  as  the  nipple,  besides  which  there  were  signs  of  left 
pleural  effusion  with  compression  of  lung.  In  the  course  of  three  days 
these  signs  increased  and  extended,  and  a  modified  bell-note  became  ob- 
tainable over  part  of  the  tympanitic  region.  On  July  22  Mr.  Pick  opened 
the  abdomen  above  the  umbilicus,  finding  a  circumscribed  cavity  beneath 
the  diaplu'agm,  into  which  the  left  lobe  of  the  liver  projected,  containin^x 
foul  gas  and  pus  mixed  with  fatty  food.  The  perforation  of  the  stomach 
was  not  found,  being  probably  closed.  On  August  12  an  empyema  of 
the  lower  part  of  the  left  pleura  was  opened,  giving  exit  to  pus  which  was 

o  2 


196  THE    STOMACH 

very  foul,  although  there  was  no  perforation  of  the  diaphragm.  The 
abdominal  wonnd  was  healed  by  August  28,  and  for  nearly  a  fortniglit 
afterwards  the  patient  made  good  progress  ;  but  then  diarrhoea  and  other 
sj'mptoms  of  septic  poisoning  set  in,  and  she  succumbed  on  September  15. 
At  the  necropsy  it  was  found  tliat  tlie  abscess  cavity  had  entirely 
contracted.  There  was  a  cicatrised  ulcer  on  the  small  curvature  and 
posterior  surface  of  the  stomach  adherent  to  the  pancreas,  the  neighbouring 
part  of  the  stomach  being  adherent  to  the  under  surface  of  tlie  left  lobe  of 
the  liver.     (Lee  Dickinson,  '  Brit.  Med.  Journ.'  1894,  vol.  i.  p.  234.) 

5.  Formation  of  fistulce. — Two  kinds  of  fistulEe  result  from 
the  perforation  of  a  gastric  ulcer.  First  there  are  those  which 
pass  between  the  stomach  and  the  bowel,  and  secondly  those 
between  the  stomach  and  the  cutaneous  surface. 

The  usual  method  by  which  a  connection  is  established 
between  the  cavity  of  the  stomach  and  that  of  the  intestine  is 
that  adhesions  are  contracted  between  the  floor  of  the  ulcer  and 
the  wall  of  the  bowel.  The  process  of  ulceration  continuing, 
perforation  takes  place,  and  a  fistula  is  formed  between  the 
two.  A  more  indirect  method  is  for  an  abscess  to  form  first 
in  connection  with  the  perforated  ulcer,  and  then  for  this  to 
burst  into  the  bowel.  In  whichever  way  the  communication 
is  established,  the  result  is  the  same  ;  an  intercommunication 
takes  place  between  the  contents  of  the  two  viscera — the  gastric 
material  passing  into  the  bowel,  and  vice  versa.  From  the  more 
constant  and  fixed  relation  of  the  colon  to  the  stomach,  a  fistu- 
lous communication  is  more  frequent  between  these  two  than 
between  the  stomach  and  the  small  intestine. 

The  symptoms  of  fistula  bimucosa  are  dependent  upon 
the  escape  of  the  faeces  into  the  stomach  and  the  gastric  con- 
tents into  the  bowel.  In  the  former  case  the  patient  will 
probably  vomit  material  which  will  suggest  the  region  of  the 
intestinal  tract  from  which  it  has  escaped  :  the  lower  down  the 
communication,  the  more  will  the  ejecta  resemble  the  character 
and  consistency  of  true  faecal  matter.  In  the  latter,  the  pre- 
mature escape  of  the  imperfectly  digested  stomach  contents 
into  the  bowel  will  give  rise  to  gradual  emaciation  ;  and  this 
will  be  more  marked  and  rapid  the  lower  the  region  of  the 
gut  opened  into. 

In  cases  of  indirect  communication,  the  sadden  bursting 
of  an  abscess  into  the  bowel  will  be  followed  by  relief  of  such 
symptoms  as  had  been  associated  with  the  process  of  sup- 


ULCER  197 

puration  ;  but,  sooner  or  later,  evidences  of  the  communication 
will  become  manifest. 

Fistulfe  between  the  stomach  and  the  external  surface  of 
the  body  arise  in  similar  ways  to  those  between  the  stomach 
and  the  intestine — either  there  is  a  direct  ulcerative  connection 
or  there  is  the  intermediate  formation  of  an  abscess.  In  addi- 
tion there  are  fistulae  which  are  artificially  produced  ;  that  is 
to  say,  they  result  from  an  endeavour  on  the  part  of  the  sur- 
geon to  secure  to  the  abdominal  incision  an  ulcer  which  has 
perforated. 

As  regards  the  treatment  of  the  former  class  of  cases,  i.e. 
where  communication  exists  between  the  stomach  and  the 
bowels,  I  have  been  unable  to  find  any  instance  of  operative 
interference.  There  can  be  little  doubt,  however,  that  where 
the  symptoms  unmistakably  point  to  a  fistula  and  the  patient's 
condition  is  one  of  gradual  decline,  an  endeavour  should  be 
made  to  deal  with  it.  What  needs  to  be  done  can  only  be 
known  after  opening  the  abdomen  and  examining  the  affected 
region.  Supposing  it  impossible  to  deal  radically  with  the 
ulcer  and  with  the  intestine — that  is  to  say,  to  excise  the  one 
and  occlude  the  orifice  of  the  other — it  might  be  found  possible 
to  detach  the  intestine,  refresh  and  suture  the  edges  of  the 
opening,  and  then  to  deal  with  the  ulcer  in  one  of  the  ways 
already  described  when  excision  is  not  feasible. 

The  treatment  of  a  fistula  which  opens  from  the  stomach 
on  to  the  surface  of  the  body  by  any  operative  procedure  is 
questionable.  In  the  first  place,  the  fistula  is  of  itself  partly  a 
curative  measure.  Complete  cicatrisation  of  the  ulcer  and  the 
stomach  would  be  followed  in  all  probability  by  a  natural  closure 
of  the  fistula ;  but  so  long  as  there  is  any  active  jjrocess  of 
destruction  going  on,  the  fistula  is  for  the  time  being  a  guard 
against  more  serious  troubles.  The  treatment  must  consist 
in  endeavours  to  protect  the  skin  from  irritation  around  the 
external  orifice.  To  prevent  the  escape  of  gastric  contents  a 
small  pad  must  be  kept  over  the  opening  ;  or  some  mechanical 
contrivance  employed,  such  as  will  be  found  in  describing  the 
methods  of  preventing  leakage  after  gastrostomy. 

Case  LIII. — Gastric  ulcer  loith  gastro-colic  sinus. 
A  young  woman  aged  22  had  always  been  subject  to  constipation,  and 
three  years  previously  had  been  attacked  with  sickness  and  vomiting, 


198  THE    STOMACH 

which  fiontinued  more  or  less  frequently  until  she  came  under  the  notice 
of  Dr.  Gordon.  Treatment  at  first  gave  relief,  but  after  six  weeks  sterco- 
raceous  vomiting  came  on.  She  died  from  exhaustion.  On  post-mortem 
exanaination  only,  sufficient  peritonitis  was  found  to  unite  the  peritoneal 
surface  of  the  stomach  to  the  transverse  colon  at  the  seat  of  the  ulcer, 
thus  preventing  the  gastric  contents  from  passing  into  the  peritoneal 
cavity  when  perforation  took  place  through  the  sloughing  of  the  base 
of  the  ulcer.  The  communication  between  the  stomach  and  colon  was 
circular  in  shape,  three  quarters  of  an  inch  in  diameter,  and  situated  in 
the  posterior  surface  of  the  stomach  two  inches  from  the  pylorus.  There 
was  an  absence  of  lienteric  stools  throughout  the  whole  progress  of  the 
case.     (Gordon,  ' Brit.  Med.  Journ.'  1892,  vol.  i.  p.  229.) 

6.  External  arlliesions. — That  adhesions  may  of  themselves 
be  a  source  of  subsequent  trouble  in  cases  of  gastric  ulcer  has 
been  recently  shown  by  a  case  brought  before  the  Clinical 
Society  of  London  by  Mayo  Eobson.' 

Sufficient  has  already  been  said  of  the  way  in  which 
adhesions  are  contracted  between  the  floor  of  the  ulcer  and 
some  neighbouring  part.  The  process  is  in  most  instances  a 
protective  one.  Except  for  the  adhesion  of  the  stomach  to 
some  other  part,  perforation  into  the  general  peritoneal 
cavity  would  be  a  much  more  frequent  occurrence  than  it  is. 
The  subject,  however,  of  adhesions,  which  will  be  more  fully 
discussed  later,  is  introduced  here  as  one  which  may  prove  a 
source  of  pain  and  annoyance  to  the  patient  after  the  cause 
which  has  given  rise  to  them  has  been  cured.  The  way  in 
which  these  adhesions  give  rise  to  trouble  seems  to  be  either 
by  unduly  fixing  the  stomach  so  as  to  impair  its  proper 
motile  function,  or,  by  altering  the  relation  of  one  part  to 
another,  to  cause  dilatation  of  the  organ.  The  result  as 
regards  the  patient's  symptoms  is  the  production  of  obscure 
abdominal  pain  accompanied  with  invalidis-m  or  debility,  with 
no  relief  by  any  form  of  purely  medical  treatment. 

The  pai't  of  the  stomach  upon  which  adhesions  are  likely 
to  produce  the  most  marked  effects  is  the  pyloric  region. 
Here  the  result  is  to  cause  some  obstruction  and  consequent 
gastric  dilatation. 

That  operation  in  certain  eases  is  capable  of  giving  com- 
plete and  permanent  relief  is  sufficiently  well  shown  by 
Eobson's    case   already   referred   to.      In    this   instance   the 

'    Trans.  Clin.  Soc.  1894  vol.  xxvii.  p.  1. 


ULCER  199 

dilatation  of  the  stomach,  which  had  followed  upon  the 
obstructing  influence  of  the  adhesions  at  the  pylorus,  dis- 
appeared after  separation  of  the  latter.  Krogius  '  also  reports 
a  case  of  successful  laparotorn}-  for  the  relief  of  serious  and 
very  painful  symptoms  caused  by  adhesion  of  the  stomach  to 
the  abdominal  wall  after  the  healing  of  a  gastric  ulcer. 

After  all  that  has  been  said  with  regard  to  the  curative 
effects  of  adhesions,  the  greatest  caution  will  need  to  be 
exercised  where  operation  is  performed,  and  particularly  so 
when  no  great  interval  exists  between  the  symptoms  of  the 
pre-existent  ulcer  and  the  symptoms  which  are  supposed  to 
be  due  to  the  resultant  adhesions.  There  is  the  possibility  of 
so  wealiening  the  part  by  the  separation  of  adhesions,  that  it 
will  be  liable  to  give  way  under  strain.  Sabrazes  ^  records  the 
case  of  an  old  ulcer  which  had  contracted  adhesion  to  a  neigh- 
bouring part.  The  patient  had  indulged  in  a  meal  which 
had  disagreed  with  him  and  provoked  vomiting.  The  result 
was  a  rupture  of  the  adhesions  between  the  stomach  and  the 
liver,  and  the  production  of  a  large  perforation.  It  should 
be  remarked  that  when  adhesions  are  separated  by  operation, 
an  endeavour  must  be  made  to  prevent  a  reunion  of  the 
disconnected  parts.  In  the  case  of  the  pylorus  this  may  be 
possible,  but  elsewhere  it  will  be  difficult. 

7.  Internal  contractions. — The  cicatrisation  of  an  ulcer 
may  lead  to  considerable  alteration  in  the  shape  of  the  cavity 
of  the  stomach.  The  more  serious  contractions  are  those  in 
connection  with  the  pylorus,  which  will  be  dealt  with  imme- 
diately ;  but  when  the  body  of  the  viscus  is  implicated,  bands 
may  be  formed,  or  the  cavity  become  narrowed.  Some  of  the 
instances  of  so-called  '  hour-glass  '  contractions  are  undoubt- 
edly the  result  of  cicatrisation  from  ulceration.  A  specimen 
exists  in  Guy's  Hospital  Museum  where  an  ulcer  similar 
to  that  which  has  given  rise  to  pyloric  stenosis  is  present 
about  the  middle  of  the  lesser  curvature  and  has  caused 
an  '  hour-glass '  contraction.  Wolfler  ^  also  records  a  case 
of  '  hour-glass  '  contraction  due  to  this  cause.  The  only 
practical  interest  connected  with  these  constrictions  is  when 

»  Centralblatt  fur  Chirurrjie,im&,'^o  22,  p.  538. 

-  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  i.  C—  12. 

'  Brit.  Med.  Journ.  Epitome,  1895,  vol.  i.  p.  30. 


200  THE   STOMACH 

the  surgeon  has  to  discuss  the  method  of  treatment  to  be 
adopted  in  cases  of  perforation.  In  Parsons's  case  already 
quoted,  the  external  circumference  of  the  stomach  at  the  seat 
of  perforation  appeared  so  small  that  no  hope  could  be  enter- 
tained of  excising  the  ulcer  completely  without  leaving  too 
great  a  constriction,  .  Wolfler,  in  his  case  of  hour-glass 
contraction,  opened  the  organ  to  the  right  and  left  of  and 
below  the  scarred  and  contracted  portion,  and  stitched  the 
edges  of  the  two  orifices  together  so  as  to  establish  a  free 
communication  between  the  dilated  cardiac  and  the  dilated 
pyloric  portions  of  the  stomach  (gastro-anastomosis).  The 
patient  made  a  good  recovery.  There  are  apparently  no 
known  symptoms  specially  associated  with  a  stomach  affected 
with  internal  contraction  due  to  excessive  cicatrisation,  so 
long  as  the  contractions  interfere  with  neither  the  cardiac 
nor  pyloric  orifices. 

8,  Pyloric  stenosis.  —  Considerable  obstruction  at  the 
pylorus  may  be  caused  by  an  ulcer  situated  at  or  in  the 
immediate  vicinity  of  the  pyloric  orifice.  This  obstruction 
may  be  brought  about  in  one  of  three  ways :  either  ifc  may 
result  from  the  amount  of  inflammatory  thickening  which 
usually  takes  place  around  the  ulcer,  or  from  cicatricial 
contraction  consequent  upon  the  healing  of  the  lesion,  or 
from  spasmodic  closure.  In  the  last  instance,  it  is  supposed 
that  reflex  contraction  of  the  pylorus  takes  place  as  the  result 
of  irritation  of  the  floor  of  the  ulcer. 

The  symptoms  which  arise  in  connection  with  obstruction 
at  the  pylorus  from  gastric  ulcer  being  more  or  less  common 
to  those  which  manifest  themselves  from  other  sources  of 
obstruction,  they  will  be  dealt  with  under  the  general  heading 
of  that  subject. 

In  like  manner  the  subject  of  treatment  will  receive  con- 
sideration under  the  same  heading.  It  may  be  merely  briefly 
indicated  here  that  stenosis  from  gastric  ulcer  has  been  suc- 
cessfully treated  by  pylorectomy,  digital  dilatation  (Loreta), 
pyloroplasty  (Heineke-Mikuliez),  and  gastro-enterostomy. 


TUMOURS  201 

CHAPTER   XXIV 

TUMOURS  IN  THE  BODY  OF    THE    STOMACH  :    INNOCENT  ;    MALIGNANT 

The  tumours  intended  to  be  discussed  here  are  such  as 
involve  neither  the  pyloric  nor  the  cardiac  orifices,  but  find 
their  seat  in  any  part  of  the  viscus  between  these  two 
regions.  As  at  the  pylorus,  the  large  majority  of  tumours 
implicating  the  body  of  the  stomach  are  carcinomatous  ;  a 
few  instances  are  recorded  of  sarcoma  ;  and  only  exception- 
ally tumours  of  an  innocent  character  are  met  with.  The 
interest  of  these  tumours  to  the  surgeon  is  mostly  when  they 
can  be  felt  through  the  abdominal  parietes,  for  unless  a  tumour 
can  be  thus  detected  externally,  the  symptoms  are  frequently 
so  obscure  that  the  case  receives  the  attention  rather  of  the 
physician  than  the  surgeon. 

Innocent  tumours. — As  examples  of  innocent  tumours, 
which  may  or  may  not  give  rise  to  symptoms,  may  be  men- 
tioned lipomata,  lipo-myomata,  fibromata,  myomata,  fibro- 
myomata,  and  lymphadenoids. 

A  specimen  of  a  lipoma  was  shown  at  the  Pathological 
Society  of  London  by  Murray,^  Coats  ^  also  figures  a  tumour 
of  the  same  structure  about  the  size  of  a  hazel  nut.  Pitt  ^ 
showed,  at  the  same  Society,  specimens  of  lymphadenoid 
growths  in  the  mucous  membrane  of  the  stomach.  One  of 
these  growths  was  an  inch  thick  and  two  inches  across.  The 
patient  had  had  no  symptoms.  Norman  *  reports  a  somewhat 
similar  case.  There  had  been  entire  absence  of  symptoms. 
'  The  mucous  membrane  was  everywhere  thickened,  and  pre- 
sented all  varieties  of  polyposis,  from  large  dendriform  projec- 
tions to  small  wartlike  growths.'  Other  references  to  similar 
cases  are  given.  A  case  of  lipo-myoma  is  reported  by  Kunze.'^ 
A  man  aged  52  j^ears  had  complained  of  pain  in  the  middle  of 
the  abdomen  for  fourteen  years.     There  had  been  no  vomiting 

'   Trcms.  Path.  Soc.  Lond.  1889,  vol.  xl.  p.  78. 

-  Manual  of  Pathology,  3rd  edit.  p.  287. 

^  Trans.  Path.  Soc.  Lond.  1880,  vol.  xl.  p.  80. 

'  Dublin  Jotirnal  of  the  Medical  Sciences,  1893,  vol.  xlv.  p.  346. 

^  Amiiial  of  the  Universal  Medical  Sciences,  1891,  vo\  i.  C— 10. 


203  THE   STOMACH 

nor  eructation.  In  the  umbilical  region  a  tumour  as  large  as 
the  fist  could  be  felt,  rough,  movable  in  all  directions,  and  with 
easily  definable  borders.  The  diagnosis  made  was  tumour  of  the 
mesentery.  On  operation  a  tumour  was  found  in  the  anterior 
W'all  of  the  stomach,  at  the  cardiac  end.  Death  occurred  in 
fifteen  days.  Cleghorn  ^  records  the  case  of  a  fibroma  or  fibro- 
myoma  which  existed  in  the  form  of  a  large  polypus  attached 
to  the  lower  border  of  the  stomach,  about  three  inches  from 
the  pylorus.  The  patient's  symptoms  evidently  depended 
upon  its  intermittent  incarceration  by  the  pyloric  sphincter. 
Pathologists  are  acquainted  with  other  forms  of  innocent 
growths,  such  as  multiple  adenomata,  fibrous  papillomata, 
pouches,  and  cysts,  but  these  give  rise  to  little  or  no  distinctive 
symptoms,  and  are  mostly  discovered  only  after  death. 

Certain  cases  of  solid  tumours  are  occasionally  met  with 
which  present  the  clinical  features  of  malignancy,  and  yet 
spontaneously  disappear.  They  are  frequently  described  as 
solid  tumours  of  the  abdomen,  without  any  special  indica- 
tion of  the  part  or  parts  with  which  they  may  be  connected, 
or  from  which  they  may  arise.  In  some  instances,  however, 
the  association  of  the  tumour  with  some  distinct  region  has 
been  noted,  and  in  these  it  has  more  frequently  been  with  the 
intestines.  In  this  connection  they  will  be  referred  to  later. 
In  a  case  recorded  by  J.  Crawford  Eenton,^  the  stomach  was 
implicated  in  a  large  tumour  which  caused  vomiting  and 
emaciation.  The  abdomen  was  opened  with  a  view  to  perform- 
ing gastro-enterostomy,  but  the  tumour  was  found  so  adherent 
that  no  operation  could  be  performed.  The  diagnosis  was 
malignant  disease.  Eighteen  months  afterwards,  the  patient 
was  quite  well ;  and  the  tumour,  which  before  operation  was 
felt  as  '  a  hard  nodular  mass,  extending  all  over  the  greater 
curvature  of  the  stomach,'  had  entirely  disappeared.  The 
probable  inflammatory  nature  of  these  tumours  will  be  further 
discussed  when  treating  of  the  same  disease  in  the  intestines. 

Malignant  tumours. — Carcinoma. — Carcinoma  is  met  with  in 
the  body  of  the  stomach  in  three  forms  :  (1)  cylinder-celled, 
(2)  spheroidal-celled,  and  (3)  colloid.  The  third  form,  how- 
ever, merely  represents  a  degenerative  change  in  either  of  the 

'  Animal  of  the  Universal  Medical  Sciences,  1893,  vol  i.  C — 17. 
-  Trans.  Path,  and  Clin.  Soc.  Glasgow,  1895,  vol.  v.  p.  176. 


TUMOURS  203 

preceding,  but  is  more  frequently  found  attacking  the  sphe- 
roidal-celled.    The  scirrhous  and  medullary  varieties  of  carci- 
noma comprise  both   the  spheroidal-celled  and  the  cylinder- 
celled,  inasmuch  as  fibrous  tissue  may  enter  very  largely  or 
very  slightly  into  the  structure  of  either  of  these  forms.     The 
tendency  of  all  forms  is  to  infiltrate  and  invade  considerable 
areas  of  the  stomach  wall ;  the  more  circumscribed  growths 
are  usually  the  cylinder-celled.     The  true  distinctions  between 
the  different  forms  of  carcinoma  are  mostly  determined  by  the 
microscope,  but  occasionally  it  is  possible  to  distinguish  them 
with  the  naked  eye.     Thus  the  colloid  presents  a  somewhat 
gelatinous  appearance,  and  the  medullary  tumour  tends  to  in- 
vade the  coats  of  the  stomach  and  form  projections  externally. 
Diagnosis. — It  is  not  intended  to  discuss  at  any  leng  h  here 
the  symptoms  of  gastric  carcinoma.     It  is  never  at  the  early 
stage  that  the  surgeon  meets  with  these  cases  ;  as  already 
indicated,  it  is  not  usually  until  a  tumour  can  be  felt,  and  the 
question  is  raised  as  to  its   possible  connections   and  likely 
nature.     It  may  be  incidentally  remarked  that  the  symptoms 
of  gastric  carcinoma  are  frequently  so  obscure  that  the  phy- 
sician is  unable  to  give  any  assistance  from  the  earlier  history 
of  the  case.     It  sometimes  happens  that  there  is  an  entire 
absence  of  any  gastric  trouble,  though  there  is  extensive  dis- 
ease in  the  organ  itself.     A  man  was  recently  under  my  care 
in  the  infirmary  suffering  from  chronic  cystitis,  for  which  he 
was  being  treated.     He  was  suddenly  taken  with  severe  ab- 
dominal symptoms  and  died  in  a  few  hours.     At  the  post 
mortem,  extensive  carcinoma  of  the  stomach  was  found,  with 
at  one  spot  an  ulcerative  perforation.     During  his  residence 
in  hospital  he  had  never  shown  any  sym])toms  of  his  gastric 
complaint.      Numerous    somewhat  similar  cases   have   been 
recorded,  where  the  most  extreme  disease  has  been  found  after 
death,  jet  during  life,  or  up  to  a  comparatively  short  time 
before  death,  there  has  been  an  entire  absence  of  any  indication 
of  the  stomach  mischief.     There  is  one  symptom  of  consider- 
able importance  to  which  attention  has  been  forcibly  drawn 
in  recent  years.     It  is  found  that  with  comparatively  few  ex- 
ceptions hydrochloric  acid  is  absent  from   the  gastric  juice 
in  carcinoma  of  the  stomach.     The  reason  of  this  Mathieu  ' 

'  Archiccs  Gcneralca  dc  Medccinc,  1889,  vol.  i.  p.  402. 


204  THE    STOMACH 

attributes  to  an  interstitial  gastritis  with  atrophy  of  a  con- 
siderable number  of  glands.  These  changes  exist  not  only  at 
the  seat  of  growth,  but  at  a  distance  from  it.  In  a  case  of  my 
own,  the  disease  was  limited  to  the  pylorus,  but  with  Giinz- 
burg's  solution  no  reaction  of  free  hydrochloric  acid  was 
obtained.  In  explanation  of  those  cases  where  HCl  is  found, 
it  is  supposed  that  there  still  remains  some  healthy  secreting 
mucous  membrane.  (For  description  of  method  of  examina- 
tion see  page  150.) 

In  some  instances,  though  rarely,  the  supraclavicular  lym- 
phatic glands  are  found  enlarged.  Troisier  ^  points  out  that 
the  glands  of  the  left  side  are  more  often  affected  than  those 
on  the  right. 

The  features  regarding  a  tumour  of  the  body  of  the  stomach, 
when  it  can  be  felt,  will  be,  in  the  first  place,  its  situation.  It 
will  be  located  more  or  less  in  the  epigastric  region,  extending, 
according  to  its  dimensions  or  according  to  the  extent  of  the 
stomach  involved,  to  either  side  or  below  this  region.  It  will 
sometimes  be  found  to  ascend  and  descend  in  respiration,  and 
to  alter  its  position  according  to  the  degree  of  distension  of 
the  stomach.  It  may  be  hard  and  painless  to  the  touch,  and 
capable  of  a  certain  amount  of  movement  by  manipulation. 
These  few  points  present  no  degree  of  certainty  in  themselves, 
but  existing  in  conjunction  with  others  will  materially  assist 
towards  a  correct  diagnosis.  In  a  case  reported  by  Franks,^  a 
tumour  hard  and  tolerably  movable  was  felt  in  the  epigas- 
trium which  moved  upwards  and  downwards  on  respiration. 
It  was  not  tender  on  ]Dressure.  On  exploring,  a  large  tumour 
was  at  once  exposed,  which  proved  to  be  a  colloid  carcinoma 
involving  the  whole  thickness  of  the  stomach  walls,  and  to 
almost  their  whole  extent. 

The  course  which  the  disease  may  take  varies.  In  most 
instances  death  sooner  or  later  ensues  from  the  emaciation 
and  exhaustion  due  to  an  increasingly  disordered  digestion. 
In  other  cases  some  serious  comj)lication  may  hasten  the  end. 
Where  ulceration  is  in  process,  a  severe  and  fatal  haemorrhage 
may  occur ;  or,  as  in  my  case,  ulceration  may  lead  to  per- 

'  Gazette  Hehclom.  de  Med.  ci  de  Chir.  1886,  p.  (383. 
'  Trans.  Acad.  Med.  Ireland,  1887,  vol.  v.  p.  24f3. 


PLATE    IX. 


-Carcinoma  of   Stomach.— The    ulcer  is  circular  in  form, 
and  the  walls  aroundare  infiltrated.     (l^V.l.-M.,  GUis.) 


FiK  17.— Carcinoma  of  Stomach. — The  ulcer  is  situated  in  the  lesser 
curvature  about  two  inches  from  ihi  pylorus.      The  existence 

of  the  ulcer  was  not  suspected  during  life.     (R  I.£M.,  Clas  ) 


TUMOURS  205 

foration.  In  a  case  recorded  by  Ducheneau,'  adhesions  formed 
between  the  tumour  and  the  abdommal  parietes  ;  the  latter 
gave  way  at  the  umbihcus,  and  the  discharge  which  took  place 
led  to  the  belief  that  it  was  simply  an  umbilical  abscess. 
A  somewhat  similar  complication  is  recorded  by  Frantzel.'^ 
An  abscess  formed  the  indirect  connection  between  the  tumour 
and  the  parietes.  This  abscess,  when  opened,  contained 
ichorous,  foul-smelling  pus  mixed  with  air  bubbles,  the  latter 
being  freely  expelled  when  the  patient  coughed.  West^ 
reports  a  case  where  adhesion  formed  between  the  stomach 
and  the  colon,  and  by  ulceration  a  communication  was  esta- 
blished between  the  two.  In  this  case  the  patient  showed  no 
symptoms  until  six  weeks  before  death.  A  similar  complica- 
tion occurred  in  a  case  recorded  by  May,''  The  patient  took 
meat  in  large  quantities  and  digested  it.  At  no  time  were  the 
stools  lienteric  in  character.  The  man  lived  four  months. 
The  nature  of  the  case  was  diagnosed  during  life  from  the 
escape  of  gas  into  the  stomach  after  injection  into  the  colon ; 
also,  that  in  washing  out  the  stomach  with  cool  water,  the 
water  was  at  once  ejected  ]jer  rectum  at  the  same  temperature. 
Treatment, — There  is  little  to  suggest  in  the  way  of  treat- 
ment from  the  purely  surgical  point  of  view.  After  the 
surgeon  has  opened  the  abdomen  and  ascertained  the  nature 
of  the  tumour  and  its  connections  be  will  in  all  XDrobability 
find  that  any  consideration  of  removal  is  out  of  the  question. 
One  of  the  most  marked  features  of  carcinoma  of  the  body  of 
the  stomach  is  its  tendency  to  extensive  invasion  of  the  walls. 
The  fact  of  being  able  to  feel  the  growth  through  the  abdominal 
parietes  almost  necessarily  implies  that  the  walls  of  the  viscus 
have  already  become  so  extensively  infiltrated  that  total  re- 
moval will  be  impossible.  Could  such  localised  lesions  as  are 
shown  in  Plate  IX  be  diagnosed,  it  might  reasonably  be  ex- 
pected that  removal  would  be  easy  and  a  cure  possible.  The 
remarkable  success  of  very  extensive  removal  by  Langenbuch  ■' 
must  be  mentioned,  if  only  to  show  what  it  is  possible  to 
accomplish.   About  seven-eighths  of  the  stomach  were  removed, 

'  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  i.  C— 24.         -  Ibid. 
3  Trans.  Path.  Soc.  Loud.  1890,  vol.  xli.  p.  97. 

*  Annual  of  the  Universal  Medical  Sciences,  1891,  vol.  i.  D— 10. 

*  Brit  Med.  Journ.  Epitome,  1895,  vol.  i.  p.  11. 


i>0«  THE    STOMACH 

and  the  two  ends  united  after  the  necessary  narrowmg  of  the 
cardiac  extremity.  Tije  stomach  then  had  the  size  of  a  hen's 
egg.  The  patient  made  a  good  recovery.  A  second  case 
was  attempted,  but  the  stomach  proved  so  friable  that  it 
tore  during  the  removal.  The  patient  succumbed  on  the 
sixth  day,  death  resulting  apparently  from  deficient  nutrition 
rather  than  from  any  untoward  result  connected  directly  with 
the  operation.  The  only  palliative  measure — if  an  operation 
may  be  so  designated — is  the  performance  of  duodenostomy  or 
jejunostomy,  whereby  the  patient  may  be  fed  by  the  bowel, 
and  so  any  troublesome  symptoms  dependent  upon  gastric 
ingestion  relieved. 

Sarcoma. — As  compared  with  carcinoma,  this  is  a  rare 
disease  of  the  body  of  the  stomach.  In  an  examination  of 
fifty  specimens  of  malignant  diseases  of  the  stomach  by  Perry 
and  Shaw,^  only  four  were  found  in  which  the  tumour  was  a 
sarcoma,  and  in  each  of  these  the  pyloric  region  was  princi- 
pally affected,  the  disease  spreading  towards  the  body  of  the 
organ.  Billroth' s  ^  well-known  case  consisted  of  an  enormous 
cystic  sarcoma  attached  to  the  greater  curvature  of  the  stomach 
and  implicating  also  the  lower  part  of  the  anterior  and 
posterior  walls.  It  was  successfully  removed.  Hadden  ^  ex- 
hibited a  specimen  at  the  Pathological  Society  of  London  of  a 
lympho-sarcoma.  It  consisted  of  a  globular  tumour  connected 
with  the  anterior  wall  of  the  stomach  close  to  the  lesser 
curvature  and  rather  nearer  the  pyloric  than  the  cardiac  orifice. 
Handford  *  also  showed,  at  the  same  Society,  a  specimen  of 
diffuse  sarcoma  of  the  stomach.  The  wall  of  the  viscus  was 
diffusely  infiltrated,  there  being  an  absence  of  any  sharply 
defined  tumour.  Ebstein  ^  reports  a  case  of  rapidly  growing 
sarcoma  in  a  man  aged  22  years  :  '  secondary  nodules  were 
found  in  the  peritoneum  and  in  one  of  the  kidneys  ;  a  degene- 
rated sarcomatous  mass  was  situated  between  the  right  auricle 
and  right  ventricle.'     Hartley ''  recorded  a  case  in  which  he 

'   Guy's  Hospital  Reports,  1891,  3rd  series,  vol.  xxxiii.  p.  137. 
2  Wiener  Med.  Wochenschrift,  1888,  vol.  xxviii.  p.  105. 
=>  Trans.  Path.  Soc.  Lond.  1886,  vol.  xxxvii.  p.  234. 

♦  Ibid.  1889,  vol.  xl.  p.  89. 

*  Ann7ial  of  the  Universal  Medical  Sciences,  1894,  vol.  i.  C— 22. 
"  Annals  of  Surgery,  1896,  vol.  xxiii.  p.  609. 


(•AKDIAC    OUSTRUCTIOX  207 

successfully  removed  from  the  posterior  wall  of  the  stomach 
a  spiiidle  celled  sarcoma.  The  patient's  chief  symptom  was 
the  occasional  vomiting  of  large  quantities  of  blood. 

As  regards  diagnosis  and  treatment,  there  is  hut  little  to 
add  to  what  has  already  been  said  in  connection  with  carcinoma 
of  the  organ.  From  the  fact  of  sarcomata  being  more  local- 
ised in  their  involvement  of  the  gastric  walls,  removal  by 
excision  may  be  considered ;  and,  as  shown  by  Billroth' s  case 
and  by  Hartley's,  the  operation  may  be  followed  by  success. 
In  most  instances,  however,  it  is  only  too  likely  that  no  clinical 
distinct'on  will  be  possible ;  and  that  the  growth  is  a  sarcoma 
and  not  a  carcinoma  will  be  a  matter  that  can  only  be  sub- 
sequently settled  by  the  pathologist. 


CHAPTER   XXV 

OBSTRUCTION    AT    THE    CARDIAC    AND    PYLORIC    ORIFICES 

Cardiac  obstruction. — Obstruction  at  the  cardiac  orifice  has 
already  been  fully  discussed  under  the  heading  of  (Esophageal 
Obstruction  ;  and  it  is  only  intended  to  refer  here  to  stenosis, 
which  has  its  origin  in  disease  strictly  within  the  stomach. 
Hilton  Fagge  held  somewhat  strongly  to  the  opinion  that 
carcinoma  did  not  arise  at  the  cardiac  end  of  the  stomach, 
that  when  found  there  it  was  really  connected  with  the  lower 
end  of  the  oesoi^hagus ;  in  other  words,  it  was  an  extension 
downwards  from  the  gullet.  Perry  and  Shaw  point  out  that 
probably  the  true  determining  feature  is  to  be  found  in  the 
histological  character  of  the  growth.  Inasmuch  as,  they  sa^^, 
every  growth  of  a  carcinomatous  character  in  the  gullet 
is  composed  of  squamous  cells,  the  structure  of  the  tumour 
being  found  to  be  either  spheroidal  or  cylinder- celled  would 
prove  its  gastric  origin.  Against  the  absolute  truth  of 
any  such  distinction  is  the  fact  that  rare  instances  have 
been  recorded  of  cylinder-celled  carcinoma  of  the  oesophagus 
(see  page  62).  Steven  '  has  reported  a  case  of  tumour  arising 
at  the  cardiac  orifice.  The  growth  was  a  diffuse  colloid  and 
columnar- celled  epithelioma,  which  apparently  had  its  origin 
around  the  entrance  of  the  oesophagus  and  sjiread  over  the 

'   Glasgow  Med.  Journ.  1888,  N.S.  vol.  xxx.  p.  457. 


208  THE   STOMACH 

anterior  and  posterior  walls  of  the  stomach.  In  cases  of  ob- 
struction at  the  cardiac  orifice,  the  disease  is  more  hkely  to 
be  of  gastric  than  oesophageal  origin,  when  the  walls  of  the 
stomach  are  considerably  invaded.  The  point  is  of  some  prac- 
tical importance  in  connection  with  the  question  of  treatment. 
Where  the  disease  has  invaded  the  stomach,  the  operation  of 
gastrostomy  may  not  be  possible,  nor  that  of  gastro-entero- 
stomy  ;  while  on  the  other  hand  duodenostomy  or  jejunostomy 
will  need  to  be  practised.  Jessett  ^  reports  having  successfully 
operated  on  two  cases  by  jejunostomy.  In  both  these  the 
disease  had  extended  too  far  over  the  anterior  walls  to  admit 
of  any  operation  on  the  organ  itself.  In  cases  upon  which  it  is 
found  possible  to  perform  a  gastrostomy  the  tube  for  feeding 
purposes  should,  as  suggested  by  Ewald,  pass  through  the 
pylorus  ;  the  reason  for  this  being  the  possibly  disorganised 
condition  of  the  stomach  for  all  digestive  purposes.  Whether 
resection  of  the  cardiac  orifice  will  ever  come  within  the  field 
of  practical  surgery,  time  alone  can  prove.  Suffice  it  to  say 
that  Levy  and  Fehleisen  ^  have  recently  devised  such  an 
operation. 

The  symptoms  connected  with  obstruction  at  the  cardiac 
orifice  are  in  all  points  similar  to  those  where  the  disease  is 
more  strictly  oesophageal.  Only  at  an  early  stage  it  may  be 
sometimes  possible,  from  the  existence  of  gastric  symptoms, 
to  connect  the  origin  of  the  disease  with  the  stomach  rather 
than  the  oesophagus. 

Pyloric  obstruction. — As  a  disease,  obstruction  at  the  pylorus 
far  outnumbers  all  other  malignant  affections  of  the  body  or 
cardiac  orifice  of  the  stomach.  While  the  cause  of  obstruction 
may  sometimes  be  obscure,  the  symptoms  are  almost  always 
unmistakable,  and  the  changes  which  sooner  or  later  follow  in 
the  organ  itself  are  usually  equally  clear. 

Causes  of  i^yloric  ohstniction. — The  various  causes  which 
give  rise  to  obstruction  at  the  pyloric  orifice  may  be  primarily 
divided  into  those  which  act  from  without  and  are  independent 
of  the  pylorus,  and  those  which  are  organically  connected  with 
the  stomach. 

Obstruction  from  without. — Any  tumour  arising  from  the 

'  Surgical  Diseases  of  the  Stomach  and  Intestines,  p.  64. 
2  Centralblattfiir  Chirurgic,  1894,  No.  31,  p.  721. 


PYLORIC   OBSTRUCTION  209 

pancreas,  liver,  omentum,  mesenteric  or  retroperitoneal  glands 
may  press  upon  and  obstruct  the  orifice.  Similarly  aneurysm 
of  the  aorta  or  coeliac  axis,  and  hydatid  cysts.  Ewald  '  quotes 
a  case  reported  by  Minkowski,  where  a  gall  stone  distended 
the  gall  bladder  and  completely  occluded  the  pylorus  by  pres- 
sure, producing  enormous  dilatation  of  the  stomach.  Cicatricial 
bands  arising  from  previous  inflammatory  mischief  in  the 
neighbourhood  of  the  pylorus  may  cause  constriction.  A  some- 
■^Ahat  unusual  cause  of  obstruction  is  reported  by  Taylor.^ 
The  patient  had  all  the  usual  symptoms,  and  when  gastrotomy 
was  performed  to  ascertain  the  nature  of  the  obstruction,  it 
was  found  that  the  pylorus  was  kinked.  The  patient  made  a 
perfect  recovery,  and  the  author  attributes  the  success  of  the 
operation  to  the  adhesions  which  subsequently  developed 
between  the  stomach  incision  and  the  abdominal  parietes, 
whereby  the  dilated  viscus  was  somewhat  raised. 

Obstruction  from  conditions  directly  connected  ivitli  the 
jnjlorus. — By  far  the  larger  number  of  cases  of  obstruction  owe 
their  origin  to  some  cause  organically  connected  with  the 
pylorus.  The  commonest  cause  is  carcinoma,  which  obstructs 
cither  by  the  thickening  it  produces  in  the  walls  of  the  orifice, 
or  by  warty,  villous,  or  nodular  projections  into  its  canal. 
AVith  rare  exceptions  the  disease  never  passes  beyond  the 
pylorus  into  the  duodenum ;  on  the  other  hand  the  fundus  of 
the  stomach  may  be  extensively  invaded.  The  form  of  car- 
cinoma is  either  the  spheroidal-  celled  or  the  cylinder-celled. 
The  former  sometimes  assumes  the  typically  scirrhous  cha- 
racter. It  is  now  generally  believed  that  many  cases,  which 
were  at  one  time  supposed  to  be  non- malignant  fibrous  thick- 
ening of  the  pylorus,  are  forms  of  scirrhous  carcinoma. 
Microscopically  little  else  than  fibrous  tissue  is  found ;  but 
when  enlarged  lymphatic  glands  are  examined,  the  presence  of 
epithelial  cells  demonstrates  the  true  nature  of  the  induration. 
Cases  of  sarcoma  of  the  pylorus  are  much  more  rarely  met 
with.  Perry  and  Shaw,  in  their  list  of  fifty  ca.ses,  record  two 
instances.  In  both  these  the  tumour  was  a  round -celled 
sarcoma,  and    extended  for   a   short  distance  into  the    duo- 

'  Lectures  on  Diseases  of  the  Stomach,  New  Sydenham  Society,  1892,  vol.  ii. 
p.  335. 

-  Lancet,  ISyi,  voL  i.  p.  983. 

P 


210  THE   STOMACH 

deniim,  differing  in  this  respect  from  the  carcinomata.  As 
ah^eady  indicated,  obstruction  may  be  caused  by  a  simple 
gastric  ulcer.  Inflammatory  thickening  around  a  progressive 
ulceration  may  cause  considerable  narrowing  of  the  canal,  and 
the  same  result  may  take  place  from  the  cicatrisation  of  the 
ulcer  in  the  process  of  healing.  Bond  ^  records  an  instance  of 
obstruction  due  to  a  state  of  chronic  reflex  spasmodic  contrac- 
tion of  the  part,  the  primary  seat  of  irritation  being  a  large 
ulcer.  A  true  fibrous  stricture  may  result  from  irritant 
poisoning. 

Among  exceptional  causes  of  obstruction  may  be  instanced 
one  recorded  by  Pernice  ^  of  a  large  myoma ;  and  another 
by  Perlik^  of  a  diverticulum  when  filled  with  chyme.  Hale 
White  ^  records  an  instance  of  thickening  of  the  pylorus  due 
to  the  irritation  of  a  gall  stone,  which  ulcerated  from  an 
adherent  gall  bladder  through  the  pylorus  into  the  stomach. 
Lastly  there  are  cases  of  congenital  stenosis. 

Symptoms. — Obstruction  at  the  pylorus,  from  whatever 
cause,  manifests  itself  insidiously.  The  earlier  symptoms  are 
those  connected  with  some  gastric  disturbance.  The  contents 
of  the  stomach  being  unable  to  obtain  a  free  exit  through  the 
pylorus,  are  thrown  back  again  upon  the  gastric  cavity,  with 
the  result  that  the  mucous  membrane  soon  suffers  and  normal 
digestion  no  longer  takes  place.  This  disorganisation  of  the 
proper  function  of  the  stomach  soon  manifests  itself  in  various 
dyspeptic  symptoms.  The  patient  complains  of  discomfort  in 
taking  food,  a  feeling  of  fulness  or  weight  in  the  region  of  the 
epigastrium,  a  sense  of  nausea,  with  furred  tongue  and  foul 
breath.  Want  of  appetite  and  a  tendency  to  refrain  from 
food  are  seen  in  those  cases  where  much  pain  is  associated  with 
ingestion.  In  other  instances  there  is  a  craving  for  food, 
and  the  stomach  is  so  tolerant  of  its  presence  that  large 
quantities  accumulate  before  being  ejected.  Tendernfss  may 
be  experienced  when  pressure  is  made  over  the  stomach. 
Headache,  depression,  and  other  neurotic  symptoms  may  be 
present. 

As  the  obstruction  becomes   more  marked,   the   various 

'  Brit.  Med.  Journ.  1889,  vol.  ii.  p.  1323. 

^  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  i.  C — 15. 

••'  Ewald,  p.  329.  '  Trans.  Patli.  Sue.  Land.  1886,  vol.  xxxvii.  p.  280. 


PVLORTC    OBSTIJUCTTOX  211 

symptoms  become  exaggerated,  and  constant  vomiting,  either 
immediately  after  food  or  at  variable  periods  later,  soon 
l)ecomes  a  prominent  feature.  Coincident  with  these  sym- 
ptoms is  a  gradual  falling  off  in  body  weight  and  strength. 
Constipation  causes  much  annoyance  and  discomfort.  When 
that  stage  is  reached  in  which  the  stomach  l^egins  to  lose  the 
power  of  returning  its  contents,  vomiting  becomes  less  fre- 
quent, fermentation  of  the  retained  food  grows  more  active, 
and  the  viscus  may  get  so  distended  with  gas  that  it  presses 
upon  the  heart  and  lungs,  and  the  patient  becomes  distressed 
both  by  palpitation  and  dyspnoea. 

Case  IjIY.-- Carcinoma  of  the  pylorus. 
Mrs.  L.,  aged  57  years,  was  admitted  to  the  Victoria  Infirmary,  Glas- 
gow, on  February  2, 1894,  under  the  care  of  Mr.  Maylard.  Her  symptoms 
commenced  about  fifteen  months  before  admission  to  the  hospital.  At 
this  time  her  most  prominent  trouble  was  the  pain  experienced  after 
taking  food,  and  so  much  annoyance  did  it  cause  that  she  was  afraid  to 
eat  anything.  She  would  also  occasionally  vomit,  the  contents  of  the 
stomach  consisting  of  but  slightly  altered  food.  No  blood  was  observed, 
but  she  states  that  her  stools  were  sometimes  almost  black.  On  admission 
to  the  infirmary  she  was  found  to  be  greatly  emaciated.  She  took  food, 
which  lay  like  a  load  on  her  stomach  for  some  hours  ;  it  then  '  soured,' 
causing  enictations  of  sour  gas  and  fluid,  and  finally  was  thrown  up  in  large 
quantity.  Palpation  of  the  abdomen  gave  evidence  of  a  tumoiu*  in  the 
epigastric  region  just  beneath  the  ribs  on  the  right  side  ;  it  was  movable 
from  above  downwards  and  also  from  side  to  side.  Succussion  produced  a 
splashing  sound.  A  '  test  breakfast '  was  administered,  and  after  removal 
and  examination  with  Glinzburg's  reagent,  revealed  no  evidence  of  free 
hydrochloric  acid.  Gastro-enterosti^ny  was  performed.  The  patient  died 
on  the  ninth  day  from  inanition,  the  resi;lt  of  a  gastric  fistula,  through 
which  everything  given  by  the  mouth  passed  out.  At  the  post  mortem, 
the  pylorus  was  found  to  barely  admit  the  tip  of  the  little  finger.  No 
secondary  deposits  were  found  in  the  liver,  spleen,  or  kidneys.  No  en- 
largement of  lymphatic  glands.  Microscopically  the  tumour  was  a 
cylinder-celled  carcinoma.    (A.  Ernest  Maylard,  Clinical  Reports,  1894.) 

Case  LV. —  Carcinoma  of  the  xyylorus. 
R.  H.,  aged  50  years,  was  admitted  into  the  Victoria  Infirmary,  Glas- 
gow, on  May  9,  1894,  under  the  care  of  Mr.  Maylard.  His  symptoms 
liad  commenced  about  eight  months  previously.  At  that  time  he  felt 
some  vague  discomfort  in  taking  his  food,  and  frequently  would  refrain 
from  doing  so  until  he  reached  home  after  his  day's  work.  He  would 
then  indulge  in  a  heavy  meal.  At  this  early  period  vomiting  only 
occm-red  occasionally.  For  the  last  three  months  his  appetite  had  been 
ravenous.     Food  was  retained  for  a  couple  of  days  or  longer,  and  then 

p2 


212  THE    STOMACH 

followed  vomiting  of  an  enormous  quantity  of  more  or  less  fluid  and  very 
sour- smelling  material.  In  his  own  words,  he  would  sometimes  bring  up 
a  '  basinful '  His  bowels  since  the  commencement  of  his  illness  have 
been  irregular  and  very  constipated.  Pain  has  never  been  a  feature  in 
his  case.  On  admission  the  patient  was  in  an  extreme  state  of  weakness 
and  emaciation.  The  abdomen  was  much  sunken,  and  an  examination 
of  the  region  revealed  an- ill-defined  sense  of  resistance  in  the  region  of 
the  pylorus.  "When  warm  water  was  run  into  the  stomach  through  a 
siphon  tube,  the  stomach  was  seen  to  distend,  and  the  greater  curvature 
could  be  easily  defined  as  it  extended  some  two  or  more  inches  below  the 
umbilicus.  The  usual  test  breakfast  given,  no  evidence  of  free  hydro- 
chloric acid  could  be  obtained.  Gastro-enterostomy  was  performed,  but 
the  patient  died  on  the  fourth  day.  From  the  time  of  the  operation  no 
urine  was  secreted.  At  the  post  mortem  there  was  evidence  of  peritonitis 
in  the  region  of  the  stomach,  but  the  union  between  the  bowel  and  the 
stomach  was  complete.  The  pyloric  stenosis  was  so  tight  that  only  a 
No.  G  catheter  could  be  passed.  Microscopical  examination  of  the  pylorus 
showed  it  to  be  affected  with  scirrhous  carcinoma.  (A.  Ernest  Maylard, 
Clinical  Eeports,  1894.) 

Diagnosis. — It  is  not  usual,  until  vomiting  has  become  a 
frequent  and  prominent  symptom,  that  pyloric  stenosis  is  one 
of  the  causes  thought  of.  The  early  dyspeptic  symptoms, 
while  sufficiently  marked  of  themselves,  are  too  suggestive  of 
so  many  other  causes  to  be  of  any  specially  diagnostic  value. 
By  the  time  vomiting  has  proved  itself  an  intractable  and  con- 
stant symptom,  two  other  conditions  may  have  sufficiently 
developed  to  aid  materially  in  arriving  at  a  correct  diagnosis. 
The  first  of  these  is  the  existence  of  a  tumour  in  the  epigastric 
or  right  hypochondriac  region  ;  and  the  second,  dilatation  of 
the  stomach. 

There  is  nothing  markedly  characberistic  in  the  tumour. 
Its  size  and  mobility  depend  upon  its  nature  and  amount  of 
fixation.  In  cases  of  a  long  gastro-hepatic  omentum,  or  of  a 
comparatively  firm  solid  tumour,  it  may  be  freely  moved  in 
all  directions ;  and  in  cases  of  very  thin  abdominal  walls,  it 
can  be  almost  grasped  with  the  finger  and  raised.  Where  the 
opposite  conditions  exist,  the  tumour  may  be  so  bound  down 
and  confined  beneath  the  right  lobe  of  the  liver  that  it  cannot 
be  palpated.  Material  assistance  will  be  obtained  in  deter- 
mining these  various  features  of  the  tumour  by  the  adminis- 
tration of  an  anaesthetic.  Supposing  a  tumour  can  be  felt, 
it  will  in  the  majority  of  instances  indicate  either  the  thick- 
ening due  to  a  gastric  ulcer  or  to  malignant  disease,  aud 


PLATE    X. 


Fig.  i8. — Carcinoma  of  Pylorus. — The  lesser  curvature  has  been  encroached  upon 
and  drawn  in  ;  the  body  of  the  stomach  is  much  dilated,     {IV.I.SM.,  Glas.) 


PYLORIC   OBSTRUCTION  213 

there  is  nothing  in  the  nature  of  the  tumour  so  felt  that  will 
help  to  distinguish  the  one  from  the  other. 

As  already  indicated  in  discussing  the  subject  of  carcinoma 
of  the  bod}''  of  the  stomach,  much  importance  has  been  at- 
tached, from  a  diagnostic  point  of  view,  to  the  existence  or 
non-existence  of  free  hydrochloric  acid  in  the  gastric  contents 
as  a  means  of  distinguishing  cases  of  ulcer  from  those  of 
malignant  disease.  In  the  former  the  acid  is  present  and 
often  in  excess,  while  in  the  latter  it  is  most  commonly  absent. 
In  all  cases  therefore  a  careful  examination  of  the  contents 
of  the  stomach  should  be  made.    (See  page  150.) 

The  dilatation  of  the  stomach  which  follows  upon  any  form 
of  obstruction  at  the  pylorus  is  important  in  so  far  as  it  helps 
to  support  the  correctness  of  the  diagnosis.  There  is,  however, 
considerable  difficulty  in  determining  such  dilatation  in  all 
except  the  most  marked  instances.  In  the  first  place  there 
is  considerable  variation  in  the  normal  size  and  capacity  of  the 
stomach,  and  in  the  second  the  methods  at  our  disposal  are 
far  from  giving  any  very  certain  results.  An  endeavour, 
however,  must  be  made  to  ascertain,  if  possible,  the  amount 
of  dilatation  present ;  for  not  only  is  it  important  from  a 
diagnostic  point  of  view,  but  it  is  a  material  advantage  to  the 
surgeon  to  know,  in  view  of  any  operation,  whether  or  not  he 
has  a  dilated  viscus  to  deal  with. 

To  avoid  repetition  here,  the  reader  is  referred  to  the 
section  on  physical  examination  of  the  stomach,  where  the 
methods  of  inspection,  palpation,  auscultation,  and  inflation 
necessary  to  be  employed  in  these  cases  are  fully  described. 
(See  page  163.) 

It  may,  however,  be  briefly  pointed  out  that  where  a  patient 
is  known  to  retain  his  food  for  twenty- four  hours  or  longer, 
and  then  bring  up  some  very  large  quantity — a  *  basinful ' 
as  it  is  sometimes  expressed — there  can  be  very  little  doubt  of 
the  dilated  condition  of  the  stomach.  Further,  the  extreme 
emaciation  which  so  often  exists,  and  the  sunken  state  of  the 
abdominal  parietes,  admit  of  a  visible  projection  of  the 
stomach  as  it  is  slowly  distended  with  water  allowed  to  flow  in 
through  a  tube.  The  quantity  which  can  thus  be  introduced, 
and  the  level  down  to  which  the  greater  curvature  extends 
below  the  umbilicus,  will  assist  in  conveying  some  notion  of 


214  THE   STOMACH 

the  amount  of  dilatation  present.  In  some  cases  a  marked 
peristaltic  action  of  the  stomach  walls  is  seen.  The  stomach 
appears  and  disappears  like  a  phantom  tiimom\  These  move- 
ments may  be  taken  as  pathognomonic  of  obstruction  at  the 
pylorus. 

Splashing  on  succussion  is  often  present,  and  usually 
indicates  some  amount  of  dilatation. 

The  diagnosis  of  the  rarer  causes  of  pyloric  obstruction  can 
in  most  instances  only  be  conjectural.  With  the  exception  of 
such  forms  of  stenosis  as  can  be  traced  to  the  imbibition  at 
some  antecedent  date  of  a  corrosive  or  irritant  poison,  it  is  not 
possible  prior  to  an  operation  to  ascertain  the  true  nature  of 
the  obstructing  agent. 

Treatment. — It  is  impossible  by  any  other  measures  than 
those  which  are  purely  surgical  to  deal  with  organic  obstruc- 
tion at  the  pylorus.  It  is  true  that  much  may  be  done  by 
such  palliative  measures  as  washing  out  the  stomach  and 
careful  attention  to  diet,  but  these  only  alleviate  for  a  time. 
Sooner  or  later  the  patient  must  sink  from  inanition.  If 
surgical  interference  is  to  be  entertained,  the  question  of  most 
moment  is,  how  long  are  these  palliative  measures  to  be  con- 
tinued before  some  radical  attempt  is  made  to  overcome  the 
obstruction  ?  The  custom  of  the  past  has  been  to  delay  any- 
thing operative  until  the  patient  is  practically  in  extremis. 
The  practice  of  the  future  will  be  to  operate  so  soon  as  a 
reasonable  diagnosis  is  arrived  at.  The  results  of  such  early 
operations  will  be  first  to  subject  the  patient  to  an  opera- 
tion from  which  he  will  have  a  much  greater  chance  of  imme- 
diate recovery  ;  second,  to  prolong  life  beyond  what  it  would 
otherwise  have  reached  ;  and  lastly,  to  give  a  chance  of  a 
permanent  recovery.  No  statistics  based  on  past  experience 
can  convey  any  adequate  impression  of  what  may  be  hoped 
for  in  the  future.  Every  surgeon's  retrospect  is  more  or  less 
a  gloomy  one.  He  mostly  recalls  cases  where  the  patient 
seemed  already  to  have  one  leg  in  the  grave,  and  his  operation 
consisted  simply  in  helping  in  the  other.  But  no  such  gloomy 
prospect  need  exist  for  the  future,  if  only  these  cases  are 
taken  early  enough :  when  the  patient  has  a  sufficient  store 
of  strength  to  draw  upon,  and  his  recuperative  powers  are 
not  just  on  the  verge  of  extinction. 


PYLORIC   OBSTRUCTION  21  o 

The  kind  of  operation  to  be  performed  depends  upon  the 
nature  of  the  obstruction.  In  cases  of  cicatricial  stenosis  such 
as  result  from  traumatism,  corrosive  poisoning,  and  ulceration, 
the  pylorus  may  be  digitally  dilated  as  by  Loreta's  method, 
or  divided  longitudinally  and  stitched  transversely  as  by 
the  Heineke-Mikulicz  operation  of  pyloroplasty.  In  cases  of 
malignant  tumour  the  operation  selected  will  depend  upon 
the  extent  of  the  disease  and  its  connections  with  adjacent  parts. 
For  a  freely  movable  and  moderately  localised  growth  pylorec- 
tomy,  or  this  operation  in  conjunction  with  gastro-enterostomy, 
may  be  performed.  Where  removal  does  not  seem  feasible, 
either  from  the  extent  of  the  disease  in  the  stomach  or  from 
its  involvement  of  neighbouring  parts  such  as  the  omentum 
and  pancreas,  gastro-enterostomy,  duodenostomy,  or  jejuno- 
stomy  may  be  performed.  In  substitution  of  these  latter 
operations  a  preliminary  gastrostomy  may  be  performed,  and 
a  tube  then  gently  passed  through  the  pylorus,  and  the  patient 
fed  directly  into  the  duodenum.  A  more  radical  measure 
than  this  last  has  been  performed  successfully  by  Bernays, 
who  after  completing  gastrostomy  scraped  away  as  much  as 
possible  of  the  obstructing  tumour,  and  so  established  a  free 
communication  between  the  stomach  and  the  duodenum. 

For  the  details  regarding  the  performance  of  these  opera- 
tions the  reader  is  referred  to  the  chapters  at  the  end  of  each 
section  on  diseases  of  the  stomach  and  of  the  intestines  re- 
spectively ;  but  there  are  certain  general  preparations  to  be 
made  before,  and  details  to  be  attended  to  after,  operation, 
which  may  be  properly  considered  here. 

Before  operation. — The  stomach  should  be  washed  out 
with  warm  water.  If  dilatation  be  marked  it  is  better  to 
wash  out  daily  for  a  week  previously.  Under  ordinary  circum- 
stances the  day  before  and  the  morning  of  the  operation  will 
be  sufficient.  The  washing  ought  to  be  efficiently  done,  and  in 
my  own  experience  nothing  answers  better,  when  it  can  be 
passed,  than  a  fair-sii^ed  ordinary  rubber  tube  with  a  large  oval 
opening  cut  in  it  quite  close  to  its  terminal  orifice.  The  other 
end  is  attached  to  a  funnel  or  filler,  which  when  raised  slightly 
above  the  patient's  head,  allows  the  fluid  to  flow  in  slowly. 
To  remove  the  fluid  the  filler  is  lowered  below  the  level  of  the 
bed  and  the  patient  requested  to  voluntarily  express  it.     This 


216  THE    STOMACH 

can  be  repeated  two  or  three  times  until  the  fluid  returned 
is  clear.  The  voluntary  propulsion  on  the  part  of  the 
patient  tends  to  get  rid  of  all  the  fluid  better  than  any 
mechanical  suction.  In  cases,  however,  of  greatly  dilated 
stomach,  the  voluntary  effort  on  the  part  of  the  patient  is  not 
sufficient,  and  the  pump  must  be  used.  When,  from  excessive 
sensitiveness  of  the  pharynx  and  gullet,  retching  is  readily 
evoked  by  the  introduction  of  the  tube,  the  soft  rubber  one 
will  not  answer,  for  the  pressure  requisite  to  get  it  down 
causes  it  to  double  up  in  the  pharynx  and  interfere  with  re- 
spiration. In  these  cases,  therefore,  it  is  necessary  to  use  the 
ordinary  stomach-pump  tube,  which  possesses  the  requisite 
amount  of  rigidity. 

The  rectum  should  be  well  cleared  of  any  faeces,  in  order 
to  place  it  in  the  best  condition  for  the  reception  of  nutrient 
enemata.  It  is  a  wise  course  to  administer  a  nutrient  enema 
containing  an  ounce  or  two  of  brandy  just  prior  to  the 
operation. 

The  abdominal  skin  should  be  properly  cleansed.  The 
extreme  emaciation  which  the  patients  have  generally  under- 
gone makes  them  all  the  more  susceptible  to  changes  of 
temperature.  Hence  every  precaution  should  be  taken  to 
maintain  the  warmth  of  the  body.  The  arms,  upper  part  of 
chest,  and  legs  should  be  well  covered  with  woollen  garments. 
In  the  room  where  the  operation  is  to  be  performed  every 
consideration  should  be  given  to  the  warmth  of  the  room  itself, 
and  of  everything  to  be  used  at  the  operation.  With  the  same 
object  the  operation  should  be  as  expeditiously  performed  as 
possible. 

After  oj^eration. — The  sum  total  of  all  after-treatment  con- 
sists in  giving  the  patient  and  the  parts  operated  upon  com- 
plete rest.  In  hospital  these  cases  should  be  placed  in  a 
separate  apartment,  and  nursed  by  a  special  nurse  day  and 
night.  Quietness  is  conducive  to  sleep,  and  sleep  to  repair. 
In  cases  where  pain  is  complained  of,  it  is  felt  to  a  very 
variable  extent.  In  cases  that  do  well  it  is  never  very  severe. 
Hypodermic  injections  of  morphia  (^  or  |  grain)  should  be 
given,  and  repeated  if  required.  Much  inconvenience  is  often 
felt  by  the  patient  during  the  first  night  or  two  from  being 
kept  in  the  supine  position.     More  good  is  gained  by  turning 


PYLORIC   OBSTRUCTION  217 

the  patient  slightly  to  one  side,  and  maintaining  the  position 
for  a  time  by  proppijig  with  a  pillow,  than  by  preventing  rest 
and  repose  by  rigidly  enforcing  the  dorsal  position.  The 
knees  should  be  kept  flexed,  to  relieve  any  tension  on  the 
abdominal  parietes.  Chloroform  sickness  is  always  an  un- 
welcome and  somewhat  dangerous  sequel  to  the  operation,  and 
unfortunately  little  or  nothing  can  be  done  to  stop  it. 

The  question  of  nourishment  is  of  the  utmost  moment.     It 
may  be  said  to  increase  in  importance  in  proportion  to  the 
degree  of  emaciation   which  exists  at  the  time  of  operation. 
For  rapidity  of  healing,  complete  rest  of  the  wounded  parts  is 
essential ;  and  this  applies  more  particularly  to  operations 
which  involve  the  accurate  stitching  of  one  viscus  to  another. 
When  therefore  the  patient's  strength  will  admit,  all  nourish- 
ment for  the  first  forty-eight  hours    should  be  by  nutrient 
enemata,  and  nothing  should  be  administered  by  the  mouth, 
except  a  little  ice  for  the  purpose  of  moistening  the  tongue 
and  fauces.     The  longer  this  method  of  nutrition  can  be  main- 
tained the  better.     Where,  however,  it  is  seen  that  the  j)atient's 
strength  is  likely  to  fail  unless  food  be  given  by  the  stomach, 
it  must  be  so  administered.     Food  has  been  given  without 
harm   in   cases   of   gastro-enterostomy    almost   immediately 
after  operation.     Jessett  ^   states  that  in  the  three  successful 
cases  of  gastro-enterostomy  which  he  has  had,  he  has  com- 
menced to  feed  at  once ;  and  argues  that  if  the  union  be 
perfect  there  can  be  no  harm  in  doing  so.^      Many  cases, 
however,    have   been   recorded   where,   through    strain  from 
vomiting  and  other  causes,  stitches  have  given   way.     It  is 
therefore  much  wiser,  so  long  as  the  patient's  strength  seems 
sufficient,  to  enjoin  perfect  rest  to  the  stomach  by  adminis- 
tering all  nourishment  _29e?-  rectum.     Food  when  first   taken 
by  mouth,  whether  early  or  late  in  the  treatment,  should  be 
of  a  bland,  nutritious,    and  easily  digestible   nature.     Milk 
will  form  the  staple  diet,  but  to  it  may  be  added  finely  ground 
farinaceous  materials.     In  like  manner  nitrogenous  food,  such 

'  Medical  Press  and  Circular,  1891,  N.S.  vol.  li.  p.  581. 

^  NoTE.^A  reference  to  these  cases,  as  reported  in  the  Clinical  Society's 
Transactions  (1892,  vol.  xxv.  p.  106),  shows  that  a  little  water  only  was  given 
on  the  first  clay,  and  not  till  the  following  or  second  day  was  a  little  food  given 
in  the  way  of  peptonised  milk. 


1^8  THE   STOMACH 

as  boiled  fish  and  boiled  fowl,  should  be  admmistered  in  a  finely 
divided  or  triturated  state,  and  the  latter  mixed  with  the  broth 
in  which  it  is  cooked.  For  suitable  enemata,  reference  should 
be  made  to  Chapter  LXXXIV,  where  various  kinds  are  given. 
The  urine  will  in  most  cases  need  to  be  withdrawn  by 
catheter. 


CHAPTEE  XXVI 

PYLORIC    OBSTRUCTION.       TREATMENT    (continued) 

Prognosis  in  respect  to  the  different  operations  —  So  much 
depends  upon  the  strength  of  the  patient  at  the  time  of  the 
operation,  that  statistics  cannot  be  said  to  have  much  value. 
A  patient  who  from  excessive  inanition  dies  shortly  after  the 
operation  ought  not  to  count  as  a  fatal  result  due  to  the 
operation.  Speaking  in  a  general  way,  an  operation  is  severe 
in  proportion  to  the  time  it  takes  to  perform  it.  Experience 
forcibly  teaches  the  truth  that  a  very  long  operation  is  a  very 
fatal  one.  An  excision  of  the  pylorus,  which  is  usually  a  com- 
paratively long  operation,  is  a  much  more  fatal  one  than  gastro- 
enterostomy. An  operation,  however,  which  seeks  to  extirpate 
the  disease  ranks  incomparably  higher  than  one  which  only 
aims  at  alleviating  for  a  time  the  patient's  sufferings. 

In  discussing  the  relative  merits  of  the  two  operations 
of  pylorectomy  and  gastro-enterostomy  in  the  treatment  of 
malignant  disease,  due  regard  must  first  be  had  to  the 
respective  intents  of  the  operations.  The  triple  object  of  the 
former  operation  is  to  remove  the  obstruction,  to  re-establish 
the  normal  passage,  and  to  extirpate  the  disease.  The  latter 
effects  a  similar  result  as  regards  the  first  two  objects,  only 
in  another  way,  while  it  leaves  the  disease  untouched. 
The  radical  distinction  therefore  between  the  two  operations 
is  that  one  seeks  to  extirpate  the  disease,  while  the  other 
leaves  it  to  take  its  course.  But,  inasmuch  as  the  severity  of 
the  operation  of  pylorectomy  is  in  the  hands  of  most  operators 
so  much  greater  than  that  of  gastro-enterostomy,  it  is  a  proper 
question  to  ask,  how  far  excision  of  the  pylorus  does  effect 
this  result. 

An  interesting  and  instructive  paper  was  published   by 


PYLORIC    OBSTKUCTIOX  219 

J.  Lindsay  Steven,  in  the  'British  Medical  Journal,'  '  dealing 
with  the  operative  treatment  of  gastric  carcinoma,  and  more 
particularly  with  pyloric  disease.  Steven  based  his  remarks 
on  nineteen  post-mortem  cases  of  carcinoma  of  the  stomacli, 
comprising  twelve  of  the  pylorus,  six  of  the  body  of  the 
stomach,  and  one  of  the  cardiac  orifice.  In  fourteen  out  of 
these  nineteen,  cases  the  liver  was  involved  either  alone  or 
with  other  parts,  and  secondary  nodules  were  noticed  in  parts 
other  than  the  liver  in  two  cases,  giving  therefore  secondary 
complications  in  sixteen  out  of  nineteen.  In  thirteen  out  of 
the  nineteen,  adhesions  were  present.  In  eighteen  out  of 
the  nineteen  the  post  mortems  were  upon  patients  who  had 
died  from  the  natural  progress  of  the  disease.  The  inference 
which  Steven  draws  from  these  statistics  is  that  operations 
upon  the  stomach  for  the  removal  of  the  disease  can  but 
rarely  effect  such  a  result.  It  need  hardly  be  pointed  out 
that  the  reasoning  here  is  based  solely  upon  pathological  data 
and  without  distinction  as  to  the  situation  of  the  growth. 
Thus  as  an  argument  against  the  advantage  of  attempting 
extirpation,  presumably  for  pyloric  stenosis,  the  author 
instances  one  case  particularly,  where  the  first  symptoms 
appeared  only  four  weeks  before  admission  ;  and  at  the  post 
mortem — death  having  occurred  about  two  weeks  after  ad- 
mission— the  liver,  which  was  three  times  its  normal  weight, 
was  infiltrated  in  every  part  by  secondary  formations.  A 
large  ulcerated  cancerous  tumour  was  discovered  near  the 
pyloric  region.  It  will  be  observed  that  this  was  not  a  case 
of  pyloric  stenosis,  but  one  essentially  of  disease  of  the 
body  of  the  stomach,  an  example  of  a  class  of  cases  totally 
distinct  in  all  their  features,  both  clinical  and  pathological, 
from  malignant  disease  of  the  pylorus.  In  pyloric  stenosis, 
symptoms,  although  often  very  obscure,  always  appear  months 
before  the  disease  produces  death ;  and  hence,  however  exten- 
sive the  secondary  formations  which  the  pathologist  may 
find  at  the  post  mortem,  it  is  reasonable  to  suppose  that 
these  may  not  be  in  existence  at  the  earliest  manifestation  of 
the  disease.  The  practical  teaching  of  these  statistics  is 
that  it  is  useless  to  perform  such  an  operation  as  pylorectomy 
with  the  intention  of  extirpating  the  disease  when  the  patient 

'  1892,  vol.  i.  p.  845. 


220  THE   STOMACH 

is  already  on  the  point  of  dying  from  it.  If  radical  measures 
are  to  be  attempted,  it  must  be  when  the  disease  is  detected 
early  in  its  course,  and  not  after  it  has  almost  concluded  it. 

Pylorectomy  must  always  be  considered  a  serious  opera- 
tion, but  its  relative  severity  will  be  greatly  diminished  when 
the  patient  is  in  a  comparatively  well-nourished  condition. 
Considering  the  operation  as  practised  in  the  past,  Hahn  ^ 
gives  the  following  statistics.  Up  to  the  year  1885,  72 
cases  had  been  operated  upon  for  carcinoma  and  10  for 
cicatrisation,  with  a  percentage  mortality  of  77  in  the 
former  and  60  in  the  latter.  From  1885  to  1891,  34 
cases  for  carcinoma  and  4  for  cicatrisation,  with  a  percentage 
mortality  of  41  for  the  former  and  25  for  the  latter. 
This  shows  that  experience  alone  has  materially  reduced 
the  death  rate  from  the  operation.  A  much  greater  reduction 
is  still  more  likely  to  ensue  when  the  operation  is  performed 
at  the  earliest  possible  period  of  the  disease.  The  statistics 
of  Guinard  ^  tell  a  somewhat  similar  tale.  Up  to  1881  he 
found  a  mortality  of  71  "43  ;  while  since  1887  it  has  been 
reduced  to  52-23.  In  four  cases  in  which  Murphy's  ^  button 
was  used  there  were  three  deaths. 

The  risks  of  the  operation  have  to  be  put  against  the 
length  of  time  which  the  patient  is  likely  to  live  without  it ; 
but  against  this  must  also  be  placed  the  possible  prolonga- 
tion to  life  which  this  operation  and  no  other  can  afford. 
James  A.  Adams,^  in  recording  a  successful  case  of  pylo- 
rectomy, in  which  he  accomplished  the  entire  operation  by 
using  the  continuous  suture  in  the  short  space  of  time  of 
an  hour,  refers  to  a  case  of  Wolfler's,  where  the  patient  lived 
in  comfort  for  five  and  a  half  years  :  to  one  of  Kocher's, 
where  after  five  and  a  half  years  the  patient  was  still  in  the 
enjoyment  of  perfect  health ;  and  to  one  of  Kydygier's,  where 
the  patient  lived  for  two  and  a  half  years.  It  must  therefore 
generally  be  a  matter  for  the  patient  to  decide,  after  hearing 
the  honest  opinion  of  the  surgeon,  whether  he  is  prepared  to 
face  the  risks  of  the  operation  for  such  benefits  as  are  possibly 

'  Berliner  klin.  Wochenschrift,  1891,  p.  853. 
2  Cancer  de  VEstomac,  p.  104. 
^  Lancet,  Murphy's  tables,  1895,  vol.  i.  p.  1011. 
'  Glasgow  Med.  Journ.  1896,  vol.  xlv.  p.  114. 


PYLOPJC   OBSTRUCTION  221 

to  be  obtained  from  it.  If  excision  of  the  pylorus  is  to  have 
an  estal)Hshcd  place  in  surgery,  it  will  be  for  early  and  not 
late  cases.  For  the  latter,  palliative  measures  alone  can  Ije 
attempted  ;  and  of  these  gastro-jejunostomy  is  most  likely 
to  find  greatest  favour. 

Gastro-enterostomy. — The  operation,  first  performed  by 
Wolfier  in  1881,  is  a  serious  one  and  frequently  fatal ;  but 
if  pylorectomy  is  to  be  restricted  to  early  cases,  and  it  to 
later,  gastro-enterostomy  has  this  advantage  in  comparison 
with  the  former,  that  when  death  does  result,  the  patient's 
life  may  not  have  been  shortened  by  more  than  a  week 
or  two.  Of  17  cases  collected  by  Jessett,^  there  were  5 
deaths,  giving  a  mortahty  of  30  per  cent.  Two  cases  died 
from  closure  of  the  opening,  one  four  months  and  the 
other  five  months  after  the  operation.  In  illustration  of  the 
value  of  using  absorbable  plates,  MagilP  has  collected  61 
cases  so  treated,  with  14  deaths,  thus  giving  a  mortality 
of  22-95  per  cent.  As  indicated  by  Guinard,^  the  success  of 
this  operation  has  varied  considerably  in  the  hands  of 
particular  surgeons.  Thus  Billroth  had  2  successes  out  of 
6  cases — a  percentage  mortality  of  66-66  ;  Eydygier  was 
successful  with  3  out  of  4  cases — a  percentage  mortality  of 
25;  Lauenstein  lost  only  2  cases  out  of  9— a  per<  entage 
mortality  of  22  ;  Czerny  lost  7  out  of  11  cases — a  percentage 
mortality  of  63*63  ;  Angerer  lost  5  out  of  6 — a  percentage 

morf-ality  of  83*33  ;   and  Liicke  lost  only   1  case  out  of  8 - 

a  percentage  mortality  of  12-5.  The  most  recent  statistics 
are  those  by  Murphy,"*  where  out  of  26  cases  in  which  his 
'  button  '  was  employed  by  different  operators  there  were  8 
deaths — a  percentage  of  30-7. 

The  combined  operation  of  Pylorectomy  and  Gastro- 
enterostomy, performed  first  by  Billroth  in  1885,  has  for  its 
object  the  removal  of  the  disease,  and  the  easier  establishment 
of  a  communication  between  the  stomach  and  the  bowel. 
The  operation,  although  a  severe  one,  has  not  been  altogether 
unsuccessful.     It  has  been  successfully  performed  by  Billroth, 

'  Trans.  Clin.  Soc.  Loncl.  1892,  vol.  xxv.  p.  106. 
*  Annals  of  Surgery,  1894,  part  xxi.  p.  313. 
^  Cancer  de  VEstomac,  p.  109. 
■■  Lancet,  Murphy's  tables,  lt<9y,  vol.  i.  p.  lUlo. 


222  THE   STOMACH 

Bull,'  Jessett,^  and  Ferguson  ;  ^  and  unsuccessfully  by  Lowson, 
and  by  Greig  Smith.^  It  is  supposed  to  be  most  suitable  for 
those  cases  where  the  disease  appears  localised,  but  it  is  too 
extensive  to  admit,  after  its  removal,  of  easy  approximation 
of  the  duodenum  to  the  stomach. 

The  operation  of  Digital  divulsion  of  the  pylorus,  first 
practised  by  Loreta  in  1882,  and  frequently  adopted  since  for 
cicatricial  stenoses  of  the  orifice,  is  far  from  being  a  safe  opera- 
tion, and  equally  far  from  being  a  successful  one.  If  not  fatal, 
the  relief  is  not  infrequently  only  temporary.  Barton-' read 
a  paper  at  the  American  Surgical  Association  in  which  he 
reviewed  the  results  of  twenty-five  cases.  Fifteen  recover,  d 
and  10  died,  giving  a  mortality  of  40  per  cent.  Kennicutt 
and  Bull,*^  in  a  collection  of  18  cases,  give  12  recoveries 
and  6  deaths,  making  a  mortality  of  33*3  per  cent.  Swain'' 
records  two  fatal  cases.  In  one  the  patient  died  with  return 
of  the  vomiting  on  the  fifth  day.  In  the  other,  death  resulted 
from  collapse  four  hours  after  the  operation.  AUingham^ 
also  records  a  fatal  case.  In  contrast,  however,  to  such  results 
must  be  placed  two  successful  cases  quoted  by  Treves.^  Tbe 
patients  had  been  operated  upon  two  years  before,  and  in 
neither  had  any  symptoms  of  recontraction  appeared. 

The  operation  of  Pyloroplasty,  performed  for  stenosis 
resulting  from  similar  causes  to  those  which  call  for  digital 
divulsion,  appears  to  be  a  safer  operation  and  more  certain 
in  its  results.  It  was  first  performed  by  Heineke  in  1886, 
and  from  that  year  up  to  1895  I  have  only  been  able  to  find 
fourteen  other  recorded  cases.  Of  these  15,  3  died,  giving 
a  mortality  of  21-42  per  cent.  Two  cases  are  reported  as 
having  been  seen  at  some  period  after  the  operation. 
Bardeleben's  case,  operated  upon  in  1888,  was  in  good  health 
in  1890.  Page  and  Limont's  case  was  perfectly  well  seven- 
teen months  after  the  operation. 

'  New  York  Med.  Jo2irn.  1891,  vol.  i.  p.  39. 

2  Lancet,  1891,  vol.  ii.  p.  921. 

3  Lancet,  Murphy's  tables,  1895,  vol.  i.  p.  1015. 

*  Lancet,  1891,  vol.  ii.  p.  1070. 

*  Trans.  Amcr.  Surg.  Assnc.  1889,  vol.  vii.  p.  102. 

•^  Annual  of  the  Universal  Medical  Sciences,  1890,  vol.  iii.  C — 23. 

'  Lancet,  1892,  vol.  i.  p.  87. 

«  Brit  Med.  Journ.  1895,  vol.  i.  p.  1095.     "  Ibid.  1889,  vol.  i.  p.  1105. 


rvLourc  obstruction  22.3 

So  far  as  these  two  operations  of  digital  divulsion  and 
pyloroplasty  are  concerned,  they  may  very  aptly  be  com- 
pared to  treatment  of  stricture  of  the  urethra  by  forciljle 
dilatation  or  rupture,  and  by  external  urethrotomy.  And 
just  as  experience  has  taught  that  complete  division  is 
more  permanent  in  its  results  than  forcible  dilatation,  so  is 
it  likely  that  pyloroplasty  will  be  found  to  have  a  similar 
advantage  over  digital  divulsion. 

The  operation  of  Duodenostomy  was  first  performed  by 
Langenbuch  in  1879.  It  consists  in  opening  the  duodenum 
just  beyond  the  pylorus.  As  it  involves  bringing  the  bowel  up 
to  the  abdominal  parietes,  it  can  only  be  practised  in  those 
cases  where  the  parts  are  freely  movable.  The  operation  has 
been  too  seldom  performed  to  admit  of  any  conclusion  being 
drawn  as  to  its  value. 

The  operation  of  Jejunostomy  may  be  considered  when  it 
is  found  that  the  disease  has  extended  from  the  pylorus  into 
the  body  of  the  stomach  to  such  a  degree  that  it  is  not  possible 
to  perform  gastro-enterostomy.  The  operation  has  more  fre- 
quently been  performed  when  the  disease  has  involved  the 
cardiac  orifice,  and  from  there  extended  into  the  body  of  the 
organ.  Two  such  cases  were  successfully  operated  upon  by 
Jessett.' 

The  passage  of  a  tube  through  the  pylorus,  after  the 
perforraa.nce  of  gastrostomy,  appears  to  have  been  carried  out 
wihh  success  by  Hahn.^  The  patient  was  fed  directly  into  the 
duodenum  and  lived  for  several  weeks.  The  same  operator, 
in  the  same  paper,  describes  another  method  of  dealing  with 
the  narrowed  pylorus.  It  consists  in  digital  dilatation  of  the 
pylorus  without  opening  the  stomach.  The  finger  pushes 
before  it  the  anterior  wall  of  the  viscus,  and  so  '  gloved  '  is 
gently  insinuated  into  the  constricted  orifice.  This  method  of 
treatment  is  only  advocated  when  gastro-enterostomy  and 
other  measures  do  not  appear  feasible.  It  was  performed  by 
Ha.hn  prior  to  the  introduction  of  gastro-enterostomy,  and 
before  also  he  knew  of  Loreta's  operation.  Hence  it  is  more 
than  likely,  as  he  himself  appears  to  indicate,  that  in  the 
particular  case  in  which  he  adopted   it,  he  would  have  pre- 

'   Trans.  Clin.  Soc.  Loncl.  1892,  vol.  xxv.  p.  105. 
'^  Berliner  klin.  Wochenschrift ,  1885,  p.  84G. 


224  THE    STOMACH 

ferred  Wolfler's  operation  had  it  at  that  time  been  a  known 
procedure. 

The  operation  of  Curetting,  which  consists  in  opening  the 
stomach  and  scraping  away  as  much  as  possible  of  the  growth 
which  obstructs  the  pylorus,  has  so  far  apparently  only  been 
practised  by  the  originator.  Bernays,  however,  had  such 
remarkably  good  results  in  the  two  cases  upon  which  he 
operated  in  1887,  that  the  operation  is  worthy  of  some  con- 
sideration.    (See  Chapter  XXX.) 


CHAPTEE   XXVII 


DILATATION.     CONDITIONS  DEPENDENT  IJPON  EXTERNAL  INFLUENCES 
SUCH    AS    ADHESIONS,    TUMOURS,    AND    SYSTEMIC    DISEASES 

Dilatation. — The  condition  of  dilatation  of  the  stomach 
has  already  been  dealt  with  in  connection  with  stenosis  of  the 
pylorus.  It  is  introduced  here,  however,  for  separate  con- 
sideration because  of  its  requiring,  under  certain  circumstances, 
separate  treatment. 

In  1892  Eobert  F.  Weir,'  of  New  York,  and  prior  to  him, 
although  unknown  to  him  at  the  time,  Bircher  of  Switzerland 
in  1890,  performed  an  operation  for  lessening  the  size  of  a 
dilated  stomach. 

In  the  case  in  which  the  operation  was  performed  by  Weir, 
the  cause  of  the  dilatation  was  pyloric  obstruction.  A.  gastro- 
enterostomy had  been  performed,  but  after  a  year  the  patient's 
symptoms  of  vomiting  and  gastric  distress  returned.  Tliat 
the  patient's  condition  was  not  due  to  closure  of  the  opening 
was  proved  by  the  audible  escape  into  the  bowel  of  gas 
pumped  into  the  stomach.  It  was  noticed  before  the  first 
operation  that  the  stomach  was  enormously  dilated,  being 
capable  of  receiving  between  eight  and  ten  pints  of  fluid.  It 
was  therefore  deemed  possible  that  the  symptoms  from  which 
the  patient  suffered  were  due  to  the  dilated  state  of  the 
stomach  alone.  Accordingly  the  abdomen  was  opened,  and 
the  stomach  lessened  in  size  by  doubling  in  a  fold  of  the  wall 
and  stitching  the  serous  surfaces  together  so  as  to  maintain 

'   New  York  Med.  Journ.  1892,  vol.  Ivi.  p.  29, 


DILATATION  225 

the  plaited  condition  thus  produced.     The  patient  recovered, 
and  was  reUeved  of  his  symptoms. 

The  three  cases  reported  upon  by  Bircher  are  fully  referred 
to  by  Weir,  in  the  report  of  his  own  case. 

In  the  first  of  these  the  patient,  a  man  aged  46  years,  had 
suffered  for  five  years  from  pain  in  his  back  which  was  relieved  by 
vomiting.  The  attacks  lasted  for  several  days.  The  stomach 
was  recognised  as  being  dilated,  and  systematic  washing  out 
and  attention  to  diet  considerably  relieved  the  symptoms. 
But  whenever  the  washing  was  stopped  the  vomiting  recom- 
menced. The  operation  of  gastrorrhaphy  was  performed,  and 
for  three  months  the  patient's  condition  continued  good.  A 
second  operation  was  then  performed,  to  remove  a  tumour  from 
the  lesser  curvature  which  had  been  noticed  at  the  first  opera- 
tion. The  patient  died  shortly  afterward.  No  note  is  given 
as  to  the  state  of  the  pylorus,  so  that  the  cause  of  the  dilatation 
does  not  appear. 

In  the  second  case  the  operation  was  performed  upon  a 
woman  aged  60  years,  who  for  four  years  had  had  symptoms 
of  dilatation.  The  cause  was  supposed  to  be  muscular  debility. 
The  result  of  gastrorrhaphy  was  to  restore  the  patient  to  per- 
fect health.  When  seen  three  months  later,  she  was  perfectly 
well,  and  with  normal  digestive  functions. 

In  the  third  case,  Bircher  operated  upon  a  man  aged  43, 
who  had  suffered  from  digestive  troubles  for  twenty- one  years. 
Vomiting  had  latterly  become  a  very  troublesome  feature. 
There  was  well-marked  splashing  on  succussion,  and  washing 
out  the  stomach  removed  a  quantity  of  undigested  food. 
Lavage  always  produced  considerable  improvement.  After 
gastrorrhaphy,  all  the  symptoms  of  dilatation  rapidly  disap- 
peared and  the  patient  remained  permanently  relieved. 

From  the  experience  gained  by  these  cases  taken  in  con- 
junction with  his  own.  Weir  concludes  that  the  class  of  cases 
for  which  this  operation  seems  likely  to  prove  of  most  service 
is  those  '  which  are  constantly  found  running  to  a  hospital, 
who  are  only  improved  temporarily  by  the  use  of  lavage,  and 
whose  progress  is  associated  with  repeated  relapses.' 

An  operation  termed  gastropexy  has  been  performed  by 
Buret  for  certain  cases  of  displacement  and  dilatation.  (See 
Operations  on  the  Stomach,  Chapter  XXVIII.) 

Q 


L>26  THE    STOMACH 

Conditions  dependent  upon  external  influences  such  as  ad- 
hesions, tumours,  and  systemic  diseases. — The  stomach  is  liable 
to  be  affected  by  various  conditions  not  immediately  connected 
with  its  structure.  These  conditions  may  be  purely  mechanical, 
dependent  upon  some  local  pressure  or  displacement  of  the 
organ ;  or  they  may-  be  more  strictly  functional,  dependent 
upon  some  interference  with  the  proper  quantitative  or  quali- 
tative supply  of  blood  to  the  part  or  with  its  nerve  supply. 
The  result  in  either  case  is  interference  in  some  way  with  the 
normal  digestive  function. 

Few  of  the  systemic  causes  fall  within  the  domain  of  the 
surgeon ;  it  is  only  when  the  cause  appears  to  be  locally 
situated  that  surgical  interference  is  called  for. 

Pressure  exerted  by  tumours  has  already  been  alluded  to 
in  discussing  the  various  causes  of  obstruction  at  the  pylorus, 
it  only  remains  to  be  said  that  the  body  of  the  stomach  may 
similarly  be  impinged  upon  by  tumours  of  a  solid  or  cystic 
character  arising  from  neighbouring  organs  or  tissues.  In 
many  cases  it  will  be  impossible  to  determine,  without  an 
exploratory  laparotomy,  whether  the  tumour  is  intrinsic  or 
extrinsic.  Where  the  disease  has  its  origin  within  the  parietes 
of  the  stomach,  the  gastric  symptoms  are  likely  to  be  more 
marked  than  in  the  opposite  condition.  Little  importance, 
however,  can  be  given  to  this  as  a  means  of  distinction,  when 
it  is  remembered  how  gravely  the  body  of  the  stomach  may 
be  involved  in  carcinoma  and  yet  the  gastric  symptoms  be 
almost  nil. 

In  some  cases,  such  for  instance  as  aneurysm  of  the 
abdominal  aorta,  symptoms  other  than  those  connected  with 
the  stomach  will  assist  in  determining  the  true  nature  of  the 
tumour. 

There  is  a  class  of  cases  which  has  received  some  little 
attention  witbin  recent  years  where,  as  the  result  of  inflam- 
mation, adhesions  have  formed  between  the  stomach  and 
neighbouring  parts,  giving  rise  to  protracted  and  irremedial 
gastric  symptoms. 

At  a  meeting  of  the  Clinical  Society  of  London  on  Octo- 
ber 13,  1893,  Mayo  Eobson  '  related  the  histories  of  two  such 
cases  which  he  had  successfully  operated  upon  for  dilatation 

'   Trans.  Clin.  Soc.  Loncl.  1894,  vol.  xxvii.  p.  1. 


ADHESIONS  227 

of  the  stomach  and  severe  pain  due  to  adhesions.  In  the  first 
case  the  adhesions  were  in  the  neighbourhood  of  the  pylorus, 
and  the  result  of  a  localised  peritonitis  caused  by  gall  stones. 
In  the  second  the  adhesions  were  similarly  situated,  but  owed 
their  origin  to  a  gastric  ulcer.  The  operation  consisted  in  both 
instances  of  detaching  the  adhesions.  The  dilatation  of  the 
stomach,  which  had  resulted  from  the  obstructive  effect  of  the 
adhesions  at  the  pylorus,  disappeared. 

A  case  of  unusual  severity  has  been  recorded  at  some 
length  by  Treves.'  In  this  case  the  operation  revealed  a 
collection  of  old  tuberculous  glands  situated  in  the  mesentery 
of  the  ileum.  The  great  omentum  was  rolled  up  into  around 
and  rigid  cord,  and  was  fixed  to  the  mass  of  the  glands  in  the 
iliac  region.  The  effect  of  this  adhesion  and  contraction  had 
been  to  draw  down  the  stomach  to  such  an  extent  that  it  was 
impossible  to  raise  it  until  the  omental  cord  had  been  divided. 
It  seems  likely  that  the  displacement  of  the  liver  and  trans- 
verse colon  downwards  also  depended  upon  the  dragging  effect 
of  the  contracted  omentum.  The  case  is  given  by  the  author 
as  an  illustration  of  Glenard's  disease,  a  disease  dependent 
upon  undue  relaxation  of  the  abdominal  parietes  and  the 
supporting  ligaments  of  the  abdominal  viscera,  whereby  the 
latter  become  displaced  downwards.  The  obvious  lesions 
found,  however,  seem  sufficient  to  explain  the  symptoms,  and 
class  it  rather  among  those  dependent  upon  displacements 
from  adhesions,  than  upon  undue  laxity  of  parietes  and 
suspensory  ligaments. 

In  a  paper  dealing  with  adhesions  and  cicatricial  bands  in 
the  abdominal  cavity  as  a  cause  of  continuous  and  severe 
colic,  Lauenstein  '^  figures  and  describes  several  cases  where 
the  stomach  was  dragged  or  pressed  upon  by  such  adventitious 
fibrous  tissue.  In  some  cases  laparotomy  was  performed  with 
permanent  relief.  Parker^  quotes  Eosenheim  as  having 
separated  adhesions  between  the  liver  and  the  stomach  in  a 
case  of  persistent  gastralgia ;  and  Hahn  as  having  separated 
adhesions  between  the  colon  and  the  stomach  where  the  same 
symptoms  were  present. 

'  Brit.  Med.  Joiirn.  1896,  vol.  i.  p.  1. 

-  Archivfiir  Idin.  Chir.  1893,  Bd.  xlv.  p.  121. 

^  Annals  of  Surgery,  1890,  vol.  xxiii.  p.  733. 


228  THE   STOMACH 

CHAPTEE  XXVIII 

OPERATIONS 


1.  LAVAGE 

2.  ASPIRATION  ' 

3.  GASTROTOMY 

4.  GASTROSTOMY 

5.  GASTRECTOMY 

6.  GASTRORRHAPHY 


7.  GASTROPEXY 

8.  GASTRO-ENTBROSTOMY 

9.  PYLORECTOMY 

10.  PYLOROPLASTY 

11.  PYLORIC    DIVULSION 

12.  PYLORIC    CURETTING 


1.  Lavage. — The  process  of  washing  out  the  stomach  has 
already  been  fully  described  under  the  Treatment  of  Pyloric 
Obstruction  (see  page  215).  It  only  remains  here  to  refer  to 
some  of  the  dangers  connected  with  the  operation  when  em- 
ployed for  any  disease  of  the  stomach. 

Fenwick/  in  an  exhaustive  article  on  the  dangers  associated 
with  lavage,  gives  syncope  and  sudden  death  as  conditions 
occasionally  happening.  He  attributes  the  results  to  sudden 
alteration  in  the  gastric  pressure,  which  brings  about  a  reflex 
condition  of  shock.  To  avoid  such  accidents,  care  should  be 
taken  not  to  empty  the  stomach  too  rapidly  or  to  introduce 
too  large  a  quantity  of  fluid  at  one  time. 

In  not  a  few  instances  symptoms  of  tetany  have  appeared 
within  a  short  time  after  the  removal  of  the  tube.  The  cases 
have  mostly  been  those  in  which  the  stomach  was  largely 
dilated.  Kussmaul  ^  gives  three  cases.  Marten  ^  records  a 
case  where  faintness  appeared  soon  after  the  tube  was 
inserted,  and  two  hours  after  its  removal  the  patient  began 
to  complain  of  stiffness  about  the  jaws  and  rigidity  of  the 
arms.  Death  ensued  four  and  a  half  hours  later.  In  a  case 
recorded  by  Collier,''  cramps  set  in  the  arms  and  legs  five 
hours  after  lavage,  and,  as  in  Marten's  patient,  death  took 
place  from  coma  twelve  hours  after  the  operation. 

That  direct  injury  may  be  inflicted  upon  the  walls  of  the 
stomach  by  the  tube  is  shown  in  a  case  recorded  by  Eoupell 
and  McWhinnie  ^  in  their  work  on  '  Poisons.'     The  injury 

'   The  Practitioner,  1892,  vol.  xlviii.  p.  241. 

-  Deutsches  Arcliiv  filr  Idin.  Med.  1809,  vol.  vi.  p.  475. 

2  Lancet,  1887,  vol.  i.  p.  74.  "  Ibid.  1891,  vol.  i.  p.  1251. 

*  Alderson,  Lancet,  1879,  vol.  i.  p.  6. 


LAVAGE.      ASPIRATION  229 

was  inflicted  by  the  suction  action  of  the  pump  in  a  case  of 
arsenical  poisoning. 

Perforation  and  rupture  have  also  followed  lavage.  The 
former  has  happened  when  the  operation  has  been  per- 
formed in  cases  of  ulceration.  The  latter  happened  in  a  case 
of  my  own  where,  three  days  after  performing  gastro-entero- 
stomy,  an  attempt  was  made  to  wash  out  the  stomach.  The 
insertion  of  the  tube  evoked  a  fit  of  vomiting,  which  caused 
the  patient  to  feel  a  sudden  and  acute  pain  in  the  pit  of  the 
stomach.  The  sequence  of  events  was  the  rapid  formation  of 
a  gastric  fistula,  and  death  from  inanition. 

Fen  wick  '  records  a  case  of  haemorrhage  following  empty- 
ing of  the  stomach  in  a  patient  suffering  from  pyloric  stenosis 
and  dilatation.  As  the  bleeding  did  not  recur  on  the  second 
lavage,  he  attributed  it  to  the  too  sudden  relief  of  tension 
in  the  walls  of  the  stomach,  consequent  on  a  rather  hasty  re- 
moval of  its  contents. 

The  power  of  the  stomach  to  absorb  somewhat  rapidly 
fluids  put  into  it,  has  led  to  more  than  one  fatal  case  of  poison- 
ing. Almqvist  ^  records  an  instance  of  profound  collajDse 
following  upon  lavage  of  the  stomach  with  a  solution  of  boracic 
acid.  Hogner  ^  mentions  a  similar  case  where  death  ensued 
in  six  days  from  the  use  of  the  same  acid. 

Wliile  thus  enumerating  some  of  the  accidents  which  have 
resulted  from  such  a  simple  j)rocess  of  treatment,  it  must  not 
be  concluded  that  the  operation  offers  objections  to  its  em- 
ployment where  it  seems  distinctly  indicated.  The  frequency 
with  which  it  is  used  by  the  physician  without  danger,  and 
the  unquestionable  advantages  attending  its  employment,  are 
out  of  all  proportion  to  the  occasional  occurrences  of  the 
above  mishaps. 

2.  Aspiration. — The  introduction  of  fluid  or  its  withdrawal, 
or  the  removal  of  gas,  by  means  of  the  aspirator  is  a  mode 
of  treatment  but  rarely  resorted  to.  Occasions,  however,  do 
occur  when  it  is  not  possible  to  successfully  reach  the  stomach 
by  way  of  the  oesophagus.     Dieulafoy  ^  records  the  case  of  a 

'   The  Practitio7ier,  1892,  vol.  xlviii.  p.  251. 

-  Schmidt's  Jahrhilcher,  1883,  vol.  cxcviii.  p.  28. 

3  Ibid.  1884,  vol.  ccii.  p.  2.S7. 

'  Treatise  on  the  Pneumatic  Aapiration  of  Morbid  Fluids.  1875,  p.  133. 


230  THE    STOMACH 

child  poisoned  throngli  the  administration  of  a  dessertspoonful 
of  laudanum  six  hours  after  birth.  All  other  means  failing, 
the  medical  attendant  resorted  to  Dieulafoy's  aspirator.  By 
its  means  he  succeeded  in  injecting  into  the  stomach  some 
strong  coffee,  which  was  then  withdrawn.  The  process  was 
repeated  half  a  dozen  times  and  the  child  was  completely 
brought  round.  Foy  '  also  mentions  a  case  where  he  success- 
fully employed  the  same  measures.  The  patient  was  '  dead 
drunk.'  The  administration  of  an  emetic  seemed  useless,  from 
the  fact  of  absorption  being  probably  nil ;  and  the  introduction 
of  the  stomach  tube  appeared  likely  to  interfere  with  the 
already  very  enfeebled  respiration.  Immediately  the  fluid 
commenced  to  flow  into  the  aspirator,  the  heart  began  to  beat 
and  the  pulse  to  be  perceptible  ;  respiration  also  recommenced. 

Putting  aside  these  somewhat  exceptional  instances  of 
the  use  of  the  aspirator,  there  is  a  class  of  cases  where  much 
good  has  attended  its  employment.  Cases  of  carcinoma  of 
the  stomach  sometimes  present  enormous  distension  of  the 
viscus  with  gas.  In  these  instances  the  heart's  action  may 
be  seriously  embarrassed,  and  death  becomes  imminent  if  relief 
is  not  given. 2 

3.  Gastrotomy. — The  operation  consists  in  an  incision  into 
the  stomach  for  the  removal  of  a  foreign  body,  for  exploratory 
purposes,  and  for  the  immediate  treatment  of  certain  con- 
stricted conditions  of  the  cardiac  and  pyloric  orifices.  The 
gastric  wound  is  closed  at  the  same  operation. 

Before  operation. — The  patient's  bowels  should  be  cleared 
out  as  well  as  possible  by  copious  enemata.  The  skin  over  the 
upper  part  of  the  abdomen  should  be  cleansed  and  prepared 
in  the  usual  way ;  and,  as  in  all  abdominal  operations,  the 
limbs  of  the  patient,  and  as  much  of  the  trunk  as  is  possible, 
should  be  clothed  in  some  woollen  material.  Every  other 
precaution  also  should  be  taken  to  maintain  the  temperature 
of  the  body. 

Operation. —  (1)  Skin  incision. — The  choice  of  the  incision  is 
determined  either  by  the  existence  of  some  definite  feature 
in  the  case,  as  the  tangible  projection  of  a  foreign  body,  or 
by  considerations  of  anatomy.     In  the  former  instance  the 

'  Dublin  Journal  of  the  Medical  Sciences,  1887,  vol.  Ixxxiii.  p.  48. 
^  Medical  Times  and  Gazette,  1873,  vol.  ii.  p.  500. 


GASTROTOMY  231 

incision  is  carried  either  obliquely  or  vertically  oVer  the 
si^ot  where  the  body  is  most  distinctly  felt ;  in  the  latter,  a 
vertical  median  incision  may  be  made  for  some  three  inches 
or  more  down^Yards  from  the  ensiform  cartilage,  or  a  curvi- 
linear or  oblique  one  from  the  median  line  outwards  to  the 
right  for  a  similar  extent,  and  about  an  inch  below  the  costal 
cartilages.  For  exploration  of  the  pylorus  the  median  incision 
is  the  better ;  while  for  exploring  the  cardiac  orifice  the  curvi- 
linear is  preferable. 

All  bleeding  vessels  in  the  abdominal  wound  must  be 
secured  prior  to  opening  the  peritoneal  cavity. 

(2)  Stomach  incision. — In  the  case  of  a  foreign  body,  the 
object  is  sought  for  in  that  situation  where  the  body  projects 
most  prominently ;  this  being  more  particularly  the  case  where 
the  body  is  sharp  pointed  and  possibly  impacted.  For  purely 
exploratory  purposes  an  endeavour  is  made  to  secure  a  point 
on  the  anterior  surface  about  midway  between  the  two  orifices. 
It  is,  however,  no  easy  matter  to  be  certain  of  the  particular 
area  secured. 

If  it  is  practicable,  the  part  of  the  stomach  wall  to  be  incised 
should  be  drawn  up  to  and  out  of  the  parietal  incision.  In 
any  case,  sponges  or  cloths  must  be  carefully  packed  around 
the  part  to  be  incised,  with  the  object  of  preventing  any 
escape  of  the  gastric  contents  into  the  peritoneal  cavity. 

To  prevent  the  possibility  of  the  stomach  slipping  back 
into  the  peritoneal  cavity  before  the  operation  is  completed, 
it  is  advisable  to  secure  it  by  a  couple  of  stitches  passed  through 
its  parietes  on  either  side  of  the  projected  line  of  incision. 
These  are  left  long  so  that  they  can  be  held  by  the  assistant. 

The  incision  in  the  stomach  is  made  transversely  to  the 
long  axis  of  the  viscus,  with  the  object  of  better  avoiding  the 
blood-vessels.  A  sharp-pointed  curved  bistoury  may  be  used 
to  complete  the  whole  incision,  or  a  puncture  may  be  first 
made,  and  then  the  wound  enlarged  with  scissors  to  the  re- 
quired extent. 

All  manipulations  within  the  stomach  must  be  carefully 
executed  ;  more  particularly  does  this  apply  to  the  extraction 
of  long  or  sharp-pointed  foreign  bodies.  In  some  instances 
it  is  advisable  to  alter  the  position  of  the  body,  so  as  to  place 
it  in  a  diameter  which  will  admit  of  its  easier  passage  through 
the  wound. 


232  THE   STOMACH 

To  close  the  gastric  wound  the  lax  mucous  membrane 
should  be  first  stitched  by  a  continuous  suture,  and  then  the 
serous  coat  doul>led  in  by  a  series  of  Lembert  stitches. 

The  wound  is  finally  cleansed,  the  long '  securing  '  stitches 
withdrawn,  and  the  sponges  or  cloths — the  number  of  which 
is  noted — removed.  The  stomach  then  slips  back  into  its 
position,  and  the  abdominal  wound  is  closed  in  the  usual  way. 

After  operation. — The  j3rincip]e  of  the  after  treatment  con- 
sists in  rest  to  the  patient  generally,  and  to  the  stomach  locally. 
The  patient  should  be  kept  in  a  quiet  room  for  three  or  four 
days,  undisturbed  by  any  other  persons  than  those  in  direct 
attendance.  Food  should  be  administered  per  rectum,  and 
only  a  little  ice  given  by  the  mouth  to  relieve  dryness  of  the 
tongue  and  fauces.  On  the  third  or  fourth  day,  if  all  has 
gone  well,  fluid  nourishment  may  be  begun  by  the  mouth  and 
gradually  increased. 

4.  Gastrostomy. — The  operation  consists  in  forming  a  fistu- 
lous connection  between  the  stomach  and  the  abdominal 
parietes,  with  the  object  of  introducing  food  directly  into  the 
cavity  of  the  former. 

Various  methods  of  operating  have  been  proposed  to  effect 
this.  The  method  usually.adopted  in  this  country,  and  also  fre- 
quently practised  abroad,  is  that  originally  suggested  byEgebert, 
although  modified  in  various  matters  of  detail  within  recent 
years.  In  order  to  distinguish  the  operation  from  those  in- 
troduced respectively  by  von  Hacker,  Hahn,  Witzel,  and  Frank, 
I  have  attached  Egebert's  name  to  it,  but  the  modifications 
introduced  by  Fenger  and  by  Howse  have  materially  assisted 
in  placing  it  among  the  established  operations  of  surgery. 

Egebert's  operation. — According  to  Greig  Smith,^  Egebert 
proposed  the  operation  in  1837,  but  Sedillot  first  practised  it 
in  1846.  It  was  not,  however,  until  1874  that  a  successful 
result  was  recorded.  In  the  interval  between  Egebert's  pro- 
posal and  Sydney  Jones's  success  the  operation  had  been 
practised  several  times  both  in  this  country  and  abroad,  but 
always  with  a  fatal  result. 

Preparation  of  the  patient  before  operation. — The  same  pre- 
parations as  advised  for  gastrotomy  should  be  employed  here. 
The  patient,  however,  from  the  nature  of  the  disease  for  which 

'  Abdominal  Surgery,  4th  edit.  p.  35i3. 


GASTROSTOMY 


233 


the  operation  is  to  be  pcvformed,  ]jeing  probably  in  a  much 
more  reduced  state  than  in  cases  for  gastrotomy,  greater  pre- 
cautions should  be  taken  regarding  all  points  affecting  the 
patient's  strength.  Expeditiousness  in  operating  is  of  con- 
sideral)le  moment.  A  nutrient  enema  containing  an  ounce 
or  two  of  brandy  should  be  administered  just  prior  to  the 
operation. 

The  operation. — The  surgeon  first  maps  out  as  well  as 
possible  the  outlines  of  the  stomach  and  the  liver.  The  ex- 
cessively sunken  condition  of  the  abdomen — receding,  as  the 
parietes  do,  backwards  from  the  ribs — renders  the  delineation 
of  the  anterior  margin  of  the  liver  not  very  difficult.  But  the 
stomach,  which  probably  occupies  a  position  high  up  behind, 
beneath  the  diaphragm,  is  not  so  easily  detected. 

The  surgeon  will  operate  most  conveniently  by  standing 
on  the  patient's  right  side. 

Skin  incision. — The  opening  into  the  peritoneal  cavity  has 
been  made  by  various  incisions.  That,  however,  known  as 
Fenger's  is  apparently  the  one  most  frequently  employed 
(see  fig.  19).  It  consists  in  carrying  the  incision  for  about 
two  inches  parallel  to  the 
costal  cartilages  on  the 
left  side  and  at  a  distance 
of  one  inch  from  the  mar- 
gins of  the  same.  The 
point  of  commencement 
of  the  incision  above  is 
determined  by  the  extent 
to  which  the  liver  de- 
scends. It  should  not 
cover  more  than  half  an 
inch  of  its  margin,  other- 
wise that  viscus  is  liable 
to  press  injuriously  uj)on 
the  upper  connecting 
stitches  of  the  stomach 
and  the  parietes. 

The  other  incisions  practised  have  been  mostly  vertical, 
carried  either  through  the  hnea  semilunaris  or  through  the 
fibres  of  the  rectus  muscle.     The  latter  incision  was  suggested 


Fig.     19.  —  Diagram     showing     Different 
Lines  of  Incision  for  Gastrostomy 

1,  Vou  Hacker's  ;  2,  Feuger's ;  2  and  3,  Habii's 


234  THE   STOMACH 

and  practised  by  Howse  with  the  object  of  getting  the  muscle 
to  act  as  a  sphincter  upon  the  opening  and  so  prevent  the 
escape  of  gastric  juice. 

As  soon  as  all  bleeding  points  are  secured  and  the  peri- 
toneal cavity  opened,  the  surgeon  introduces  his  index  finger, 
in  an  upward  and  backward  direction,  to  search  for  the  stomach. 
Some  difficulty  may  be  encountered  in  finding  it,  from  its  con- 
tracted condition  and  situation  behind  and  high  up  beneath 
the  diaphragm.  The  colon  is  liable  under  sach  circumstances 
to  present  itself,  and  without  proper  care  may  be  mistaken 
for  the  stomach  and  stitched  to  the  wound.  To  avoid  any 
such  fault  the  finger  should  be  passed  up  the  under  surface 
of  the  left  lobe  of  the  liver  to  the  portal  fissure,  then 
downwards  along  the  gastro-hepatic  omentum  to  the  lesser 
curvature  of  the  stomach,  and  so  on  to  its  anterior  surface. 
As  a  further  means  of  distinguishing  the  stomach  from  the 
colon,  it  may  be  pointed  out  that  the  former  is  much  thicker 
in  its  walls,  and  of  a  more  decidedly  pinkish  hue. 

The  stomach  wall  is  hooked  up  by  the  finger,  and  then, 
between  it  and  the  thumb,  brought  out  at  the  wound.  If  there 
appears  to  be  much  traction  upon  the  organ,  a  portion  of  the 
anterior  wall  must  be  obtained  where  no  such  dragging  exists, 
and  in  every  case  the  endeavour  should  be  made  to  get  a  part 
of  the  stomach  nearer  the  cardiac  than  the  pyloric  orifice. 

Fixation  of  the  stomach. — As  with  the  skin  incision  so  with 
the  fixation  of  the  stomach  to  the  abdominal  wound,  there  are 
many  ways  in  which  it  may  be  accomplished.  Two  ends, 
however,  have  to  be  prominently  borne  in  mind  whatever  the 
means  employed.  First  the  stomach  must  be  so  secured  that 
for  the  time  being  it  cannot  slip,  and  for  the  future  some 
guide  exists  for  the  subsequent  opening  of  the  viscus ;  and, 
second,  that  a  comparatively  broad  surface  of  stomach  wall  is 
made  to  adhere  to  the  parietes  around  the  wound. 

The  simplest  way  of  effecting  the  first  object  is  to  pass  a 
couple  of  '  sling '  silk  stitches  through  the  two  outer  coats  of 
the  stomach,  between  which,  when  drawn  taut,  the  subse- 
quent opening  will  be  easily  made,  and  by  means  of  which  the 
further  stitching  of  the  organ  to  the  parietes  will  be  more  readily 
effected.  In  order  to  obtain  a  broad  surface  of  coaptation  be- 
tween the  peritoneal  surfaces  of  the  stomach  and  the  parietes 


GASTROSTOM  Y 


235 


one  of  three  methods  may  be  adopted.  In  that  practised  by 
Howse,'  the  stomach  is  pulled  well  to  the  side  opposite  to  that 
to  which  the  stitches  are  successively  inserted.  A  needle 
threaded  with  silk  is  passed  through  the  peritoneal  and 
muscular  coats  of  the  stomach,  and  then  made  to  transfix  the 
abdominal  parietes  about  an  inch  from  the  wound.  The  other 
end  of  the  silk  is  then  threaded  and  also  made  to  transfix  the 
abdominal  wall  close  to  the  other.  Some  eight  or  ten  stitches 
are  passed  in  a  similar  manner  completely  round  the  wound. 
These,  when  drawn  taut  and  tied,  bring  a  complete  circle  of 
the  stomach  surface  into  close  apposition  with  the  parietes. 
If  necessary  a  stitch  or  two  should  be  inserted  at  each  end  of 
the  incision  to  lessen  its  extent ;  and,  lastly,  to  ensure  greater 
security  a  series  of  interrupted  sutures  may  be  passed  around 
the  edges  of  the  skin  incision,  taking  up  at  the  same  time  the 
peritoneal  coat  of  the  stomach. 

The  method  recommended  by  Greig  Smith  ^  should   be 
adopted  when  it  is  deemed  probable  that  the  second  stage 


Figs.   20   and  21. — Diagrams    showing   Fixation   of    the    Stomach  to  the 
Paeietes  foe  immediate  opening  in  Gasteostomy.     (Greig  ymith) 

cannot  be  delayed  and  the  stomach  must  be  opened,  if  not  at 
the  first  operation,  at  least  a  day  or  two  after  (see  figs.  20 
and  21).     He  thus  describes  his  method : 

'  Heath's  Dictionary  of  Surgery,  p.  590. 
^  Abdominal  Surgery,  4th  edit.  p.  372. 


236  THE    STOMACH 

'  Firstly,  following  Bryant's  excellent  suggestion,  insert  two 
loops  of  silver  wire  near  the  spot  where  the  opening  is  to  be 
made.  By  these  the  stomach  is  manipulated  during  the  pro- 
cess of  suturing,  and  they  serve  to  fix  it  when  the  opening  is 
made.  Then,  with  a  round  needle  threaded  with  thick  soft 
silk  about  a  foot  long,  pass  a  continuous  suture  in  a  circle  of 
about  two  inches  in  diameter,  under  the  peritoneal  and  mus- 
cular coats  of  the  stomach.  At  every  third  quarter  of  an  inch 
in  the  circle  the  needle  is  taken  out  and  reinserted;  so  that 
six  or  eight  free  loops,  about  an  inch  and  a  half  in  length,  are 
left  protruding  on  the  serous  surface.  Then,  at  corresponding 
situations  in  the  abdominal  wall,  a  handled  needle  with  a 
hooked  eye  (Tait's  needle  serves  the  purpose  admirably)  is 
pushed  through  and  catches  up  the  loops  one  after  the  other. 
As  each  loop  is  drawn  through,  a  piece  of  rubber  tubing  is 
slipped  under  it.  The  loops  are  pulled  with  moderate  tight- 
ness over  the  rubber  tubing  from  each  end  of  the  incision. 
Finally  the  ends  of  the  silver  sutures  are  hooked  under  the 
tubing,  and  serve  to  keep  the  exposed  portion  of  the  stomach 
well  up  in  the  gaping  wound.  A  suture  at  each  end  of  the 
wound  may  be  necessary.' 

Jessett '  has  more  recently  advocated  a  procedure  which 
he  adopts  for  the  operations  of  duodenostomy  and  jejunostomy, 
as  well  as  for  gastrostomy.  In  describing  it  for  the  former  he 
states :  '  A  loop  is  obtained  sufficient  to  be  easily  drawn 
through  the  abdominal  wound.  I  then  pass  a  long  straight 
needle  armed  with  silkworm  or  chromic  gut  beneath  the  serous 
and  muscular  coats  of  the  intestine  in  a  longitudinal  direction 
for  from  one  to  two  inches,  first  on  one  side  of  the  convex 
surface,  then  on  the  other ;  these  two  sutures  run  parallel  to 
each  other  and  are  about  an  inch  apart.  I  next  pass  two  more 
needles  armed  with  sutures  across  from  the  points  where 
the  longitudinal  threads  escape.  I  thus  have  a  parallelogram 
enclosed  between  my  four  sutures ;  each  of  these  is  now 
passed  through  the  abdominal  parietes  about  half  an  inch  on 
each  side  of  its  cut  edge  and  then  through  a  decalcified  bone- 
plate  with  an  opening  in  the  centre '  (as  shown  in  figs.  22  and 
23).     '  The  threads  are  next  held  in  clamp  forceps,  while  the 

'   Surgical  Diseases  of  the  Stomach,  p.  61. 


GASTROSTOxMY 


237 


})arietal  wound  is  closed  in  the  ordinary  way.     The  threads 
arc  then  tied  firmly  over  the  bone  plates,  first  the  lateral 


Fig.  22.— Diagram  showing  the  First  Steps  in  Jkjdnostomy.     (Jessett) 

a,  bone  plate  ;  h  h,  abdominal  parietes. 


Ftg.  23.— Diagram   sifowing   the    Operation    completed   ry  pulling  up    and 

transfixing     the    wall     of     the     bowel     or     ST03IACH     BY    A    PIN,    AND    TYIKG 
THE    STITCHES    OVER    THE    BONE    PLATES.    (JcSSett) 

threads  and  then  the  end  threads ;  and  finally  a  portion  of 
the  intestine  is  drawn  up  through  the  opening  in  the  bone 


238  THE   STOMA.CH 

plate  and  transfixed  with  a  bare-lip  pin  which  rests  on  the 
bone  plate.  The  abdominal  wound  is  closed  by  a  couple  of 
silkworm- gut  sutures  at  each  end.' 

The  wound  is  dressed  antiseptically,  and  left  from  three  to 
five  days  before  the  second  stage  of  the  operation  is  proceeded 
with. 

Opening  the  stomach. — While  this  is  usually  executed  on 
the  third,  fourth,  or  fifth  day,  it  may  prove  necessary,  from 
the  low  condition  of  the  patient,  to  perform  the  operation 
earlier.  The  great  advantage,  however,  of  delay  is  to  secure 
as  firm  and  perfect  adhesion  of  the  stomach  to  the  parietes 
as  possible,  and  so  prevent  any  contamination  of  the  general 
peritoneal  cavity  by  the  escape  of  the  gastric  contents.  This 
practical  division  of  the  operation  into  two  stages,  which  has 
so  materially  advanced  it  along  the  lines  of  greater  safety,  is 
due  mostly  to  Howse. 

To  form  a  communication  with  the  stomach,  the  two 
temporary  silk  sling  stitches  are  gently  drawn  upon,  and  a 
sharp-pointed  tenotomy  knife  is  plunged  into  the  cavity  of  the 
stomach,  sufficiently  far  to  ensure  of  its  having  cleanly  per- 
forated the  mucous  membrane.  By  the  aid  of  a  probe  or 
director,  inserted  after  the  withdrawal  of  the  knife,  an  india- 
rubber  tube  or  a  piece  of  an  ordinary  gum-elastic  catheter  of 
No.  8  size  is  inserted.  The  external  end  of  the  tube  or  catheter 
is  plugged  and  the  wound  cleansed,  dusted  with  iodoform, 
and  protected  with  a  little  absorbent  antiseptic  dressing.  For 
this  stage  of  the  operation  there  is  no  need  of  an  angesthetic. 

In  cases  where  there  is  manifest  evidence  of  the  patient 
nee'ling  speedy  nourishment,  opportunity  may  at  once  be 
taken  to  introduce  some  milk  and  stimulant  immediately  after 
the  tube  has  been  inserted  into  the  stomach. 

Aftej-  treatment. — For  the  few  days  which  intervene  between 
the  two  stages  of  the  operation,  the  patient's  strength  should 
l)e  maintained  solely  by  nutrient  eneraata.  The  wound  may 
not  need  to  be  touched ;  and  where  vomiting  proves  trouble- 
some after  the  angesthetic,  care  should  be  taken  to  give  good 
support  to  the  abdomen  by  well-applied  binders. 

When  the  stomach  has  been  opened  after  the  usual  interval 
of  time,  attention  is  mostly  devoted  to  the  proper  feeding  of 
the  patient. 


(lARTItOSTOMV  239 

A  glass  fnnnol  or  filler  is  attached  to  the  indianibber  tube 
directly  connected  with  the  stomach,  or  to  the  piece  of  tube 
which  has  been  affixed  to  the  catheter,  if  the  latter  is  used 
as  the  direct  means  of  communication.  In  either  case  the 
distance  between  the  parietes  and  the  filler  should  be  about 
eighteen  inches.  The  food  first  administered  should  be 
entirely  liquid,  so  as  to  pass  readily  through  the  tube  or 
catheter.  It  should  be  warmed  and  from  five  to  ten  ounces  in 
quantity.  The  amount  given  should  depend  upon  what  the 
jjatient  has  been  accustomed  to  take  pi'ior  to  the  operation. 
In  cases  of  almost  complete  obstruction  of  the  oesophagus 
small  quantities  only  should  be  administered  at  first.  As  to 
the  nature  of  the  food,  milk  with  egg  and  some  stimulant  will 
be  the  most  suitable  mediumto  commence  with  ;  later,  soups  ; 
and,  finally,  ground-up  meats  may  be  added.  The  frequency 
with  which  food  should  be  given  will  depend  upon  the  quantity 
which  the  stomach  can  bear  at  a  time.  When  only  a  little  is 
taken,  feeding  will  be  necessary  every  hour  or  two.  Durino- 
the  intervals  of  the  meals  the  filler  should  be  removed,  the 
tube  plugged  and  fixed  by  a  bandage  to  the  chest. 

The  tube  should  be  changed  every  day,  and  finally  removed 
when  the  fistula  appears  to  be  established.  At  this  jperiod  the 
patient  has  usually  learned  to  feed  himself,  and  in  some 
instances,  after  inserting  the  tube,  he  prefers  to  first  masticate 
tlae  food  so  as  to  enjoy  the  taste,  and  then  eject  it  into  the  filler 
by  which,  with  the  aid  of  some  fluid,  he  is  able  to  transmit  it 
to  the  stomach.  T()  enable  the  patient  to  introduce  food  of  a 
more  solid  character,  larger  tubes  have  to  be  introduced. 
Although  this  may  prove  an  advantage  in  one  way,  it  renders 
the  escape  of  gastric  juice  from  the  stomach  more  probable 
and  so  is  likely  to  give  rise  to  troubles  of  skin  irritation  around 
the  wound.  In  any  case,  when  this  complication  arises,  some 
artificial  jneans  must  be  adopted  to  try  to  prevent  it.  One 
method  is  to  use  the  von  Hacker-Scheimpflug  canula,  which 
consists  of  a  double  rubber  balloon.  Golding-Bird,'  after  open- 
ing the  stomach  by  an  incision  sufficient  to  admit  a  No.  10 
catheter,  dilates  the  aperture  with  tents  till  a  short  piece  of 
rublier  tube,  the  thickness  of  the  forefinger,  can  be  introduced 
and  tied  ?w  situ.     The  tube,  which  only  just  projects  into  the 

'  Brit.  Med.  Journ.  189G,  vol.  i.  p.  IG. 


240  THE    STOMACH 

stomach  and  about  one  inch  externall}^  is  kept  corked.  The 
supposed  advantage  of  this  method  is  that  the  gastric  muscu- 
lature, from  being  gradually  dilated,  and  not  incised  or  ruptured 
by  sudden  stretching,  contracts  like  a  sphincter  upon  the  tube, 
and  so  prevents  any  leakage.  Harrison  Cripps  ^  introduces  a 
small  indiarubber  disc  about  the  size  of  a  shilling,  threaded 
with  silk.  It  is  drawn  taut  when  within  the  stomach,  and 
the  ends  of  the  silk  tied  over  a  roll  of  lint  placed  over  the 
external  orifice.  In  three  cases  in  which  it  was  tried  it  effec- 
tually prevented  the  escape  of  the  gastric  juice.  Cotterell  ^ 
effects  much  the  same  object  by  means  of  a  small  indiarubber 
valve  attached  about  three  inches  from  the  end  of  a  Jacques 
catheter.  The  valve  closes  like  an  umbrella  when  being  in- 
troduced, but  when  within  the  stomach  it  expands  again.  A 
thicker  piece  of  indiarubber  is  then  slipped  over  the  catheter 
and  rests  on  the  skin,  being  fastened  to  the  catheter  by  a  couple 
of  small  safety  pins.  But  sometimes  all  mechanical  contri- 
vances fail,  and  it  is  chiefly  for  this  reason  that  various  other 
operations  have  been  devised  to  try  and  surmount  by  natural 
measures  this  troublesome  sequel  to  the  operation. 

Results. — Up  to  1874,  as  already  stated,  the  operation 
was  uniformly  fatal ;  since,  however,  the  introduction  of 
antiseptics  and  the  more  advanced  knowledge  obtained  in 
connection  with  all  abdominal  operations,  the  operation  has 
come  to  occupy  a  place  among  the  perfectly  feasible  and  safe 
practices  of  surgery.  Performed,  however,  as  it  often  is,  on 
patients  greatly  reduced  in  strength,  one  of  the  most  serious 
hindrances  to  success  is  due  to  this  cause.  Death  from  shock 
and  exhaustion,  therefore,  must  always  rank  as  grave  risks 
in  considering  the  chances  of  operation.  Failing,  however, 
these,  the  only  dangers  within  the  first  few  days  are  death  from 
inanition,  and  septic  mischief.  Should  the  patient  survive  well 
the  second  stage  of  the  operation,  life  will  be  prolonged  till 
death  results  from  the  natural  progress  of  the  disease,  if,  as 
most  frequently  happens,  the  operation  has  been  performed 
for  malignant  disease  of  the  oesophagus. 

Vo7i  Hacker's  oi:)eration? — By  this    method   the  operator 

'  Brit.  Med.  Journ.  1896,  vol.  i.  p.  1383. 

2  Ibid.  p.  1557. 

^  Wienermcd.  WocJienscJirift,  1880,  vol.  xxxvi.  pp.  1073-1110 


IfASTliOSTo.M^'  O.JI 

seeks  to  obtain  some  clieck  to  the  escape  of  the  stomach 
contents  through  the  fistula. 

A  vertical  incision  about  three  inches  in  length  is  carried 
downwards  from  a  point  a  finger's  breadth  below  the  costal 
cartilages  on  the  left  side  and  an  inch  from  the  median  line. 
This  incision  exposes  the  belly  of  the  rectus  muscle,  the  fibres 
of  which  are  separated  but  not  cut  (see  fig.  18).  Gerard,  in 
order  to  obtain  a  more  efficient  sphincter  action,  crosses  the 
fibres  of  the  muscle.  Slight  modifications  of  this  incision  are 
practised  by  other  surgeons.  Both  Howse  and  Jacobson  ^ 
deal  with  the  rectus  in  a  somewhat  similar  way  to  von  Hacker, 
only  the  skin  incision  made  by  each  is  different.  The  end, 
however,  aimed  at  of  securing  the  fibres  of  the  rectus,  for  a 
sphincter  to  the  fistula,  is  far  from  being  uniformly  attained. 
Von  Hacker  has  himself  been  forced  to  use  mechanical  mea- 
sures to  prevent  the  escape  of  the  gastric  contents. 

Hahn's  operation.'^ — Prompted  by  the  same  motive,  to 
operate  in  such  a  way  that  leakage  from  the  stomach  could 
not  take  place,  Halin  performed  in  1887  gastrostomy  by  a 
method  quite  different  from  that  usually  practised.  The 
usual  oblique  incision  about  an  inch  below  the  costal  arch  is 
first  made  through  the  abdominal  parietes,  and  the  peritoneal 
cavity  opened.  A  second  incision,  about  two  inches  in  length, 
is  then  made  in  the  eighth  intercostal  space,  close  to  the  point 
of  union  of  the  eighth  and  ninth  costal  cartilages  (see  fig.  18). 
The  peritoneal  cavity  is  opened  by  a  small  incision,  which  is 
further  enlarged  to  a  sufficient  extent  by  opening  a  pair  of 
dressing  forceps.  By  introducing  the  forefinger  through  the 
first  incision,  the  stomach  is  sought  for  as  previously  described ; 
and  when  secured  between  the  forefinger  and  thumb  of  the 
left  hand,  the  dressing  forceps  is  passed  through  the  inter- 
costal incision  and  made  to  grip  firmly  a  fold  of  the  anterior 
wall  of  the  organ.  The  forceps  is  then  withdrawn,  bringing 
with  it  the  secured  fold  through  the  intercostal  incision.  The 
stomach  is  then  stitched  to  the  wound,  and,  if  the  condition  of 
the  patient  will  allow,  not  opened  for  the  space  of  a  few  days. 

In  discussing  the  merits  of  the  operation,  which  he  has 
performed  eight  times,  Hahn  afiirms  that  there  is  no  danger 

'  Operations  of  Surgery,  p.  764. 

-  Centralblatt  filr  CJiimrgie,  1890,  No.  11,  p.  193. 


242  THE    ST0MAC;H 

of  opening  the  pleural  cavity,  nor  of  injuring  the  diaphragm, 
and  claims  that  a  small  and  contracted  stomach  can  be  more 
easily  fixed  in  this  position  :  that  the  attachment  of  the  parts 
is  more  secure,  and  stitches  are  less  likely  to  be  attacked  by 
the  contents  of  the  stomach  :  that  it  is  easier  to  administer 
nourishment,  and  the  escape  of  the  gastric  contents  is  pre- 
vented by  the  clamp-like  action  of  the  costal  cartilages ;  and, 
lastly,  that  no  means  for  closing  the  orifice  is  necessary,  nor 
is  it  possible,  from  the  protective  action  of  the  cartilages,  for 
the  fistula  to  become  unduly  large.  While  Hahn  appears  to 
have  had  no  untoward  complications  in  his  cases,  Meyer ' 
records  that  von  Hacker  and  Hadra  both  saw  necrosis  of 
cartilage  after  it. 

WitzeVs  operation.^ — In  1891  Witzel  published  an  account 
of  this  operation.  Since  that  time  it  has  been  performed  by 
several  surgeons,  and  with  almost  uniform  success  in  the  cases 
recorded.  As  in  the  preceding  operations,  the  chief  object  of 
the  method  is  to  prevent  leakage  from  the  gastric  fistula.  In 
this  it  appears  to  have  been  quite  successful. 

It  is  performed  by  opening  the  abdomen  by  the  same 
oblique  incision  as  used  in  Egebert's  operation.  The  stomach 
is  then  sought  for,  in  a  similar  way,  and  the  anterior  wall 
brought  out  of  the  wound  to  as  great  an  extent  as  possible. 
A  small  opening  is  made  into  the  cavity  of  the  stomach,  into 
which  is  inserted  an  indiarubber  tube,  some  six  inches  in 
length  and  about  the  thickness  of  an  ordinary  lead  pencil. 
Two  parallel  folds  of  the  stomach  wall  are  pinched  up  and 
united  together,  by  a  series  of  Lembert  sutures,  over  the  tube 
which  is  applied  to  the  stomach  wall  (see  figs.  24-26). 
This  oblique  passage  should  be  about  two  inches  in  length. 
The  free  end  of  the  tube  passes  out  of  the  abdominal  wound, 
while  the  stomach  is  stitched  to  the  parietes,  and  the  rest  of 
the  wound  closed.  Before  putting  a  plug  into  the  tube,  or 
clamping  it  with  a  pair  of  forceps,  an  ounce  or  two  of  milk 
may  be  inserted  through  it  into  the  stomach.  "When,  however, 
the  condition  of  the  patient  will  admit  of  two  or  three  days' 
delay,  it  appears  better  to  keep  the  stomach  quite  at  rest  and 
feed  by  nutrient  enemata. 

'  Annals  of  Surgprj/,  1893,  vol.  xvii.  p.  590. 
-  Centralblatt  fur  Cliirurcjie,  1891,  p.  001. 


GASTROSTOMY 


'24i 


The  non-escape  of  anything  through  the  fistula,  Witzel 
explains  by  the  assumption  that  a  valvehke  occlusion  is 
most  probably  formed   at  the   inner   opening.     In  the  post 


Fig.  24. 


Fig.  25. 


Fig.  26. 


IGS.    24,     25,    AND    26. PlAGKAMB    OF     WiTZEL'S    OPERATION,     SHOWING     METHOP 

OF    STITCHING    THE    TUBE    INTO    THE    STOMACH    IN    GASTROSTOMY.       (Meyer) 


R  i 


244 


THE   STOMACH 


mortem  of  a  case  recorded  by  Meyer  ^ — the  patient  dying  on 
the  fifth  day  from  bilateral  pneumonia— a   nipple-like  pro- 


FiG.  27. 


Fm.  28. 

Figs.  27  and   28. — Diageams   showing   Frank's   Method   of   Surcutaneously 
Fixing  the  Stomach  in  Gastrostomy.     (Meyer) 

tuberance  was  observed  at  the  point  of  entrance  of  the  tube, 
which  it  was  considered  would  effectually  prevent  any  escape 
of  the  gastric  contents. 

'  Annals  of  Surgcrii,  1893,  vol.  xvii.  p.  >  j  I, 


GASTRECTOMY  215 

With  regard  to  the  tube,  should  it  inadvertently  slip  out 
it  can  easily  be  reinserted.  In  one  of  Witzel's  original  cases 
he  always  removed  the  tube,  reinserting  it  when  a  meal  was 
to  be  administered. 

In  cases  where  the  operation  is  performed  for  non- 
malignant  stricture  of  the  oesoj)hagus,  the  fistula  may  be 
allowed  to  close  so  soon  as  the  stricture  is  well  dilated.  In 
one  of  Mikulicz's  cases  the  fistula  closed  sixteen  days  after 
the  stricture  had  been  successfully  stretched  and  the  tube 
removed  from  the  stomach. 

Frank's  operation. — In  some  respects  this  operation  re- 
sembles Hahn's.  Instead,  however,  of  the  stomach  being 
secured  to  an  incision  placed  between  the  ribs,  it  is  fixed  beneath 
a  bridge  of  skin  to  a  second  incision  slightly  above  the  first. 
It  was  performed  by  E.  Frank  in  Albert's  clinic  in  1892. 

The  first  steps  of  the  operation  are  the  same  as  those  of 
Egebert's.  A  second  incision  is  made  parallel  to  and  about 
an  inch  and  a  half  above  the  first,  over  the  costal  cartilages. 
The  skin  is  then  dissected  up,  so  as  to  form  a  narrow  bridge. 
Beneath  this  a  fold  or  cone  of  the  stomach  is  pulled  and  fixed 
to  the  margins  of  the  second  incision  (see  fig.  27).  An  open- 
ing is  made  into  the  stomach,  and  the  mucous  membrane 
stitched  to  the  skin.  Ssabanejew,  to  whom  also  belongs  the 
credit  of  having  devised  the  operation  some  two  years  before 
its  performance  by  Frank,  performed  it  four  times  ;  in  each 
case  leakage  was  easily  prevented.  Frank  reports  four  suc- 
cessful cases,  and  Meyer,'  who  refers  to  these  eight  cases., 
adds  three  of  his  own,  one  of  which  gave  a  good  result ;  the 
other  two,  though  fatal,  were  not  considered  fair  tests  of  the 
operation. 

5.  Gastrectomy. — The  operation  of  gastrectomy  consists  in 
the  removal  of  a  part  of  the  body  of  the  stomach.  The  more 
correct  nomenclature  for  the  operation  would  be  partial  gas- 
trectomy ;  for,  although  the  stomach  has  been  entirely  removed 
successfully  in  dogs,  the  operation  in  the  human  subject 
is  understood  to  imply  the  removal  of  a  portion  of  the  body 
organ,  the  removal  of  the  pylorus  constituting  the  operation 
of  pylorectomy.  It  must,  however,  be  noted  that  Langen- 
buch  has  twice  removed  almost  the  entire  human  stomach 

'  American  Journal  of  the  Medical  Sciences  189'1  vol.  cviii.  No.  4,  p.  400. 


24R  THE   STOMACH 

for  carcinoma.     In  the  case  which  recovered,  seven-eighths  of 
the  viscus  was  excised.     (See  page  205.) 

In  preparing  the  patient  for  operation,  the  bowels  should 
be  emptied  by  copious  enemata,  and  just  prior  to  the  operation 
a  nutrient  enema  with  some  stimulant  should  be  given.  In 
cases  where  it  is  admissible,  the  stomach  should  be  washed 
out  for  a  few  days  previously,  and  also  on  the  morning  of  the 
operation.  The  skin  over  the  abdomen  is  cleansed  in  the 
usual  way.  The  skin  incision  varies  in  position  and  extent 
according  to  the  region  of  the  stomach  to  be  dealt  with.  As 
in  most  instances  the  first  part  of  the  operation  is  performed 
with  the  object  of  ascertaining  the  nature  and  extent  of  the 
disease,  the  incision  is  usually  made  in  the  median  line. 
When,  however,  a  distinct  tumour  is  felt,  the  incision  is  carried 
in  such  a  direction  and  to  such  an  extent  as  will  best  enable 
that  part  of  the  stomach  to  be  freely  and  easily  dealt  with. 

In  a  successful  case  of  gastrectomy  reported  by  Porges,' 
the  tumour  was  felt  to  be  about  the  size  of  a  fist ;  and  in  order 
to  obtain  the  requisite  space  a  transverse  incision  nearly  eight 
inches  in  length  was  carried  two  inches  below  the  xiphoid 
cartilage,  from  the  middle  of  the  right  rectus  muscle  to  the 
left  costal  cartilage.  The  resected  piece  was  7*2  inches  long 
and  7  inches  broad. 

To  remove  any  portion  of  the  body  of  the  stomach  the 
part  to  be  excised  should  be  drawn  well  out  of  the  wound, 
and  the  peritoneal  cavity  shut  off  by  sponges  or  cloths 
packed  in  around.  To  prevent  the  stomach  from  slij^ping 
away,  when  once  well  withdrawn,  two  silk  '  sling '  sutures 
should  be  used,  each  suture  being  passed  through  both  the 
serous  and  the  mugcle  coats  to  an  extent  sufficient  to  give  a 
secure  hold,  and  just  outside  the  line  of  the  part  to  be  re- 
moved. If  a  choice  exists  of  the  direction  in  which  the 
incisions  may  be  made  in  the  stomach,  they  should  be  carried 
transversely  to  the  long  axis  of  the  organ.  By  this  means 
fewer  vessels  will  be  cut  than  if  the  incisions  were  carried 
in  the  opposite  direction,  parallel  to  the  greater  and  lesser 
curvatures. 

After  removal  has  been  effected  and  the  bleeding  points 
secured,  the  lax  mucous  membrane  is  sutured  by  a  continuous 

'  Anniial  of  tlie  Universal  Medical  Sciences,  1892,  vol.  iii.  C — 5. 


GASTRORRIIAPIIY  247 

stitch,  and  the  serous  surfaces  united  by  a  series  of  Lemberts. 
The  gastric  wound  being  finally  cleansed  and  the  '  sling ' 
stitches  and  the  sponges  or  cloths  removed,  the  stomach 
is  allo^Yed  to  drop  into  the  abdomen.  The  parietal  wound  is 
then  closed  and  the  usual  antiseptic  dressings  applied,  with  a 
firm  binder  securely  fixed  over  all. 

The  after  treatment  of  the  case  should  be  in  every  respect 
similar  to  that  described  in  cases  of  gastrotomy.  Both  the 
patient  and  the  stomach  should  be  kept  as  quiet  as  possible, 
all  feeding  for  the  first  few  days  being  b}'  the  rectum. 

6.  Gastrorrhaphy. — The  operation  of  gastrorrhaphy  consists 
in  diminishing  the  size  of  an  enlarged  stomach,  by  doubling 
in  a  portion  of  the  wall,  and  stitching  together  the  apposing 
folds.  The  operation  was  first  performed  by  Bircher,  of  Aarau, 
Switzerland,  who,  unknown  to  Weir  of  New  York,  had  operated 
on  three  cases  prior  to  the  latter.  Weir,  independently  of 
any  such  knowledge,  had  successfully  operated  in  a  similar 
way. 

Bircher  operated  in  the  following  way :  '  The  stomach 
was  x^reviously  washed  out  and  carefully  emptied.  Parallel 
to  the  left  edge  of  the  ribs  an  incision  six  inches  long  was 
made,  and  the  peritoneum  opened.  The  stomach  was  drawn 
out.  The  edges  of  the  wound  being  pulled  apart  and  the  lower 
edge  being  pulled  upward,  the  greater  curvature  of  the 
stomach  was  readily  reached,  and  sewed  to  the  lesser  curvature 
by  means  of  thirty-five  silk  stitches.  This  was  aided  by  laying 
a  long  forceps  on  the  stomach  walls  after  fixing  a  suture  at 
each  end  of  the  fold  so  that  its  weight  pushed  inward,  for  the 
time  being,  the  stomach  fold  and  allowed  readier  suture.  The 
stitches  were  passed  through  the  mucous  and  muscular 
layers.  The  wound  was  closed,  and  prompt  healing  took 
place.'  For  six  days  thereafter,  nutrition  was  carried  on 
only  by  enemata ;  and  on  the  twelfth  day  the  patient  was  up. 

In  the  second  of  Birch er's  cases  the  fold  was  made  '  more 
vertically  oblique  ;  '  while  in  both  the  other  eases  the  fold 
was  parallel  to  the  long  axis  of  the  stomach. 

Weir  '  dealt  with  the  stomach  in  the  following  way  :  *  In 
the  centre  of  the  space  between  the  upper  and  lower  borders 
of  the  stomach,  a  dimpling  in  of  the  gastric  wall  was  made 

'   Nciv  York  Med.  Joiini.  1S92.  vol.  ii.  p.  29. 


248  THE    STOMACH 

first,  by  pressure  of  a  sound,  to  a  distance  say  of  an  inch.  A 
row  of  eight  or  ten  interrupted  silk  sutures  was  now  made 
j)assing  through  the  serous  and  muscular  coats  for  a  distance 
of  from  six  to  eight  inches,  and  the  sound  withdrawn.  A 
second  series  of  sutures  at  about  an  inch  from  the  first  was 
again  made,  dimpling  in  an  additional  portion  of  the  stomach 
wall,  and  in  a  similar  manner.  A  third  and  fourth  row  of 
interrupted  silk  sutures  were  applied,  until  through  a  distance 
of  some  four  or  five  inches  the  greater  curvature  was  applied 
to  the  lesser  curvature.  When  the  row  was  completed,  a 
double  fold  of  the  stomach,  estimated  equal  to  the  breadth 
of  the  hand  and  nearly  its  length,  had  been  made  in  such  a 
way  that  this  projected  into  the  cavity  of  the  stomach.' 

For  the  first  six  days  the  patient  was  fed  entirely  with 
nutrient  enemata,  but  after  that  was  allowed  beef  tea  by  the 
mouth. 

Brandt  '  also  records  a  successful  case  under  the  title  of 
gastroplication. 

7.  Gastropexy. —  Under  this  name  Duret  ^  describes  an 
operation  which  he  successfully  performed  for  a  case  of  dis- 
placement and  dilatation  of  the  stomach,  called  by  Glenard 
gastroptosis.  The  operation  consisted  in  opening  the  abdo- 
men and  fixing  by  sutures  to  the  abdominal  wall  in  their 
normal  position  the  displaced  pylorus  and  lesser  curvature. 


CHAPTEE   XXIX 
OPERATIONS  {continued) 


8.  Gastro-enterostomy  (gastro-jejunostomy,  gastro-ileostomy, 
gastro-colostomy) . — By  the  operation  of  gastro-enterostomy 
is  understood  the  formation  of  a  permanent  communication 
between  the  stomach  and  the  bowel.  The  opening  into  the 
latter  may  be  in  any  part  of  its  course.  It  is  most  usual, 
however,  that  the  connection  is  with  the  jejunum,  hence  the 
synonym  gastro-jejunostomy.     When  the  junction  is  with  the 

'    Gentralblatt  filr  Chirurgie,  1894,  No.  16,  p.  361. 
-  Revue  de  Chirurgie,  1896,  No.  6,  p.  426. 


( i  ASTliU-ENTKlKJSTOxM  Y  249 

ileum,  it  is  strictly  a  gastro-ileostomy ;  and  when  with  the 
colon,  a  gastro-colostomy.  The  operation  described  here  will 
be  the  more  commonly  performed  one  of  gastro-jejunostomy. 

Proposed  originally  by  Wolfler  in  1881,  it  has  been  modified 
in  various  points  of  detail  since  ;  and  it  may  still  be  said  to 
be  far  from  settled  what  is  the  best  course  to  pursue  through- 
out. The  original  plan  of  carefully  stitching  the  stomach  to 
the  bowel  has,  with  many  American  and  English  surgeons, 
given  place  to  the  more  rapid  means  of  uniting  the  surfaces 
by  bone  plates,  metal  buttons,  or  other  like  material,  A 
disposition,  however,  exists  on  the  part  of  many  surgeons, 
especially  in  German  schools,  to  practise  the  original  method. 
Whichever  method  is  adopted,  the  essential  details  require 
paramount  attention.  First,  the  operation  must  be  performed 
as  expeditiously  as  possible  ;  and,  second,  the  union  of  the 
bowel  to  the  stomach  must  be  absolutely  secure.  Failure  in 
proper  attention  to  one  or  both  of  these  important  details  has 
been  a  not  uncommon  cause  of  an  unsuccessful  result. 

The  preparation  of  the  patient  for  the  operation,  and  the 
after  treatment,  have  been  fully  discussed  on  page  215. 

Wolfler's  ojjeration. — The  skin  incision  is  usually  in  the 
median  line,  between  the  ensiform  cartilage  and  the  umbilicus, 
and  from  three  to  four  inches  in  length.  After  all  bleeding 
points  are  secured  and  the  peritoneal  cavity  opened,  a  search 
is  made  for  the  upper  part  of  the  duodenum.  This  is  best 
effected,  and  with  most  certainty,  by  first  turning  the  omentum 
up  and  to  the  left,  and  then  taking  the  first  loop  of  intestine 
felt  in  the  left  hypochondrium.  Trace  up  that  end  of  the 
loop  which  appears  most  likely  to  lead  to  the  duodenum,  and 
when  thus  verified  select  a  portion  which  when  applied  to  the 
stomach  will  not  cause  traction.  Jessett  ^  gives  the  following 
directions  :  '  Push  the  omentum  over  to  the  right  and  pass 
the  index  finger  of  the  left  hand  down  until  it  feels  the  top  of 
the  kidney,  and  then,  following  this  to  the  vertebral  column,  a 
notch  will  be  felt  in  the  peritoneum  which  is  the  point  at 
which  the  jejunum  commences.  Seize  this,  and  follow  it 
downwards  until  you  have  sufficient  to  apply  easily  to'  the 
stomach.'  The  loop  of  bowel  chosen  should  then  be  clamped 
— that  is,  after  squeezing  the  contents  away  in  both  directions 

'   Medical  Press  and  Circular,  1891,  vol.  i.  p.  608. 


250 


THE   STOMACH 


— the  gut  should  be  encircled  at  two  places  about  three  or  four 
inches  apart,  either  by  a  piece  of  indiarubber  tubing,  made 
to  perforate  the  mesentery,  tightened  and  secured  by  a  pair 


Fig.  29. — Method  of  Clamping  Intestine  with  Eubbee  Tube  and 
FoKci-PEESsuRE  FoKCEPS.     (Barker) 


Fig.  30.  Fig.  32.  Fig.  31. 

Figs.  30,  31,  and    32  show  one   pair    of   Dissecting  Forceps  with   blades 

OPEN     and    rubber    TUBES    ON     BLADES     READY    FOR    USE  ;     AND    A     SECOND     PAIR 
with    blades    CLOSED    BY    PASSING  A    SMALL    PIECE    OF    TUBE     OVER     THE    POINTS 

OF  THE  BLADES.     (Maylard) 

of  catch  forceps  as  practised  by  Barker  (see  fig.  29),  or  by 
two  pairs  of  dissecting  forceps.     This  latter  method  I  have 


GASTKO-ENTEROSTOMY  251 

adopted  on  several  occasions  and  found  it  easily  and  rapidly 
done.  On  to  each  blade  of  the  forceps  a  piece  of  rubber 
tubing   is   previously  slipped.     One  blade  is  forced  through 


Fig.  33  shows  two  paies  of  Dissecting  Forceps  clamping  the  Bowel, 

(Maylard) 

the  mesentery  close  to  the  bowel,  and  the  two  blade-ends  are 
then  clamped  by  a  piece  of  tubing  slipped  over  both  (see  figs. 
30-33).  A  third  and  very  simple  method  I  saw  adopted  in 
Billroth' s  clinic.  A  few  strands  of  worsted  which  had  been 
properly  sterilised  were  twisted  together  so  as  to  make  a  soft 
cord.  Two  pieces  of  these  were  passed  through  the  mesentery 
and  tied  moderately  tight  around  the  bowel.  In  whichever 
way  secured,  the  loop  of  bowel  is  laid  upon  the  abdomen  and 
carefully  protected  with  warm  cloths.  The  stomach  is  next 
sought  for,  and  the  part  of  the  anterior  wall  selected  should 
be  nearer  the  pylorus  than  the  great  cul-de-sac.  The  organ 
is  drawn  as  far  as  possible  outside  the  wound.  Sponges 
or  cloths,  secured  with  a  long  thread  of  silk  so  that  they 
can  be  easily  withdrawn,  are  packed  around  the  protruding 
viscera  inside  the  peritoneal  cavity.  The  loop  of  bowel  is 
next  uncovered  and  applied  to  the  stomach  in  such  a  way 
that  when  the  communication  is  established  the  contents  of 
the  stomach  will  be  driven  into  the  bowel  in  the  direction 
of  the  normal  peristalsis  of  the  latter.  This  important  detail 
was  suggested  by  Eoekwitz,  and  is  sometimes  expressed  as 
giving  a  half-turn  to  the  loop.  Prior  to  the  opening  of  either 
viscus  a  row  of  stitches  may  be  placed  below  where  the 
incision  is  to  be  made.  This  serves  to  better  secure  the  parts 
in  position  when  the  openings  are  cut.  This  preliminary 
union  of  the  parts  should  be  about  an  inch  and  a  half  from 


252  THE    STOMACH 

the  greater  curvature.  An  incision  about  an  inch  and  a  half 
in  length  is  made  in  the  long  axis  of  the  bowel,  and  an  incision 
of  the  same  length  a.nd  direction  in  the  stomach.  Each  of 
these  incisions  is  made  only  through  the  serous  and  muscular 
coat,  tbe  mucous  for  the  time  being  remaining  intact. 
Union  is  effected  for  part  of  the  circumference  by  stitching 
together  the  apposing  serous  and  muscular  coats.  Tbe 
mucous  coat  is  then  punctured  in  each  viscus,  and  the  openings 
enlarged  to  a  sufficient  extent.  As  at  this  stage  the  cavities 
of  the  two  viscera  are  opened,  great  care  must  be  taken  that 
escape  of  either  the  gastric  or  intestinal  juice  does  not  con- 
taminate the  serous  surfaces  arouud.  The  apposing  free 
margins  of  the  mucous  membranes  are  united  by  a  continuous 
suture  or  by  a  series  of  interrupted  sutures  of  silk  or  gut, 
and  when  thus  a  complete  mucous  channel  is  established,  the 
remaining  part  of  the  circumference  of  the  ununited  serous 
surfaces  is  completed.  The  method  of  suturing  adopted  is 
that  known  as  the  Czerny-Lembert.  (For  the  application  of 
the  various  sutures  used  in  gastro-intestinal  surgery,  see  the 
chapter  upon  the  Operations  upon  the  Intestines.)  The  part, 
after  being  cleansed,  should  be  finally  examined  by  rotating  it 
round,  which  can  usually  be  easily  done.  At  any  point  where 
there  appears  inefficient  apposition  of  surfaces  a  Lembert  suture 
should  be  inserted.  To  avoid  kinking  or  bending  of  the  bowel, 
as  happened  in  cases  operated  upon  by  Billroth  and  Kocher,  the 
method  adopted  successfully  by  Barker^  should  be  employed, 
that  is,  a  few  additional  Lembert  stitches  should  be  passed 
between  the  gut  and  the  stomach  for  an  inch  or  so  beyond 
those  employed  for  the  union  of  the  two  orifices. 

Any  sponges  or  cloths  inserted  for  protection  into  the 
abdominal  cavity  are  removed,  and  the  sutured  parts  allowed 
to  drop  back  into  position.  The  abdominal  wound  is  closed 
and  dressed  in  the  usual  way,  and  a  firm  binder  applied  around 
the  abdomen. 

The  needles  used  for  uniting  the  bowel  and  the  stomach 
should  be  the  ordinary  sewing  needles — that  is  to  say,  needles 
without  cutting  edges — curved  to  nearly  a  half-circle. 

Senn's  operation. — The  most  important  modification  of  the 
operation  which  has  been  introduced  within  recent  years  is 

'   Brit.  Med.  Journ.  1886,  vol.  i.     .  292. 


GASTRO-ENTEllOSTOMY  2r>:^ 

that  by  Senn.  It  consists  in  approximating  the  parts  by 
means  of  decalcified  bone  plates,  and  thereby  materially 
shortening  the  period  over  which  the  operation  extends. 

In  1889  Senn^  published  the  results  of  his  experiments 
upon  dogs,  which  proved  the  safety  of  the  operation  so  far  as 
these  animals  were  concerned,  and  suggested  its  feasibility  for 
adoption  in  the  case  of  the  human  subject. 

Probably  the  first  case  of  gastro-enterostomy  performed  in 
this  country  with  bone  plates  was  by  T.  Kilner  Clarke."^ 

The  plates  to  be  used  are  thus  prepared  by  Senn  :  '  The 
compact  layer  of  an  ox's  femur  or  tibia  is  cut  with  a  fine  saw 
into  oval  plates,  one-fourth  of  an  inch  in  thickness,  two  and 
a  half  to  three  inches  in  length,  and  an  inch  in  width.  The 
plates  are  then  decalcified  in  a  ten-per-cent.  solution  of  hydro- 
chloric acid  changed  every  twenty-four  hours,  until  they 
have  become  sufiiciently  soft  to  be  bent  in  any  direction 
without  fracturing.  After  decalcification  they  are  washed 
by  letting  water  flow  over  them  from  three  to  six  hours  so 
as  to  remove  the  acid.  The  plates  are  then  covered  with 
porous  paper  and  compressed  between  two  pieces  of  tin 
until  they  are  perfectly  dry.  If  during  the  process  of  drying 
the  plates  are  not  compressed  between  two  smooth  surfaces 
they  become  distorted  by  warping.  The  hardened  plates  are 
next  drilled  several  times  in  a  straight  line  in  the  centre,  and 
the  openings  enlarged  and  connected  with  a  file  until  the 
perforation  is  five-eighths  of  an  inch  in  length  and  about  one- 
eighth  to  one-sixth  of  an  inch  in  width.  The  sharp  margins 
of  the  plate  and  perforations  are  removed  with  a  file.  With 
a  fine  drill  the  four  perforations  for  the  sutures  are  made 
near  the  margin  of  the  oblong  perforation,  one  at  each  end 
and  one  at  each  side.  For  preservation  the  plates  are  kept  in 
absolute  alcohol.  When  they  are  to  be  used  they  are  washed 
in  a  two-per-cent.  carbolic  acid  solution,  and  the  threads  or 
sutures  attached  by  threading  two  fine  sewing  needles  each 
with  a  piece  of  aseptic  silk  twenty-four  inches  in  length,  which 
are  tied  together.  The  threads  are  then  fastened  to  the  sur^ 
face  of  the  plate  by  another  thread  passing  through  the  perfo- 
rations in  the  shape  of  a  loop  and  fastened  at  the  back'  (see 
fig.  34).     (For  the  method  of  threading  the  plates  see  Chapter 

*  Intestinal  Surgery,  p.  179.  -  Brit.  Med.  Jomii.  1889,  vol.  ii.  p.  1089. 


254 


THE    STOMACH 


LXV,  on  Operations  upon  the  Intestines.)  The  first  stages  of 
the  operation  are  similar  to  those  described  in  Wolfler's  method. 
As  soon  as  the  selected  parts  of  the  bowel  and  the  stomach 
are  sufficiently  withdrawn,  an  incision  is  made  about  an 
inch  and  a  half  in  length  in  the  long  axis  of  the  bowel. 
The  two  lateral  threads  of  the  bone  plate  are,  by  means  of 
needles,  made  to  pass  through  the  wall  of  the  bowel  about  a 
quarter  of  an  inch  from  the  opening  and  midway  between 
the  two  ends.     The  stitches  are  passed  from  within  out,  and 


Fig.  34. 


-Peefoeated    Decalcified   Bone   Plate,  theeaded   and    eeady 
FOE   USE.     (Senn) 


as  they  are  drawn  taut,  the  plate  is  slipped  in  through  the 
opening  and  drawn  into  position.  The  remaining  two  stitches 
are  brought  out  through  the  wound  at  each  end.  The  ends 
of  these  threads  are  secured  and  taken  charge  of  by  the 
assistant,  while  the  surgeon  proceeds  to  follow  out  a  similar 
procedure  upon  the  stomach. 

The  plates  are  now  brought  together  so  that  the  two 
openings  appose  each  other.  The  lower  lateral  threads  are 
tied  first,  the  end  ones  next,  and  the  upper  lateral  last.     To 


GASTRO-ENTEROSTOMY  i^oo 

obtain  greater  security,  the  serous  surfaces  may  be  scarified 
before  bringing  them  together  ;  and  after  the  plate  threads 
have  been  tied,  a  few  Lembert  stitches  may  be  passed  between 
the  serous  surfaces  of  the  two  viscera  at  the  margins  of  the 
plates.  The  operation  is  completed  as  in  W51£ler's  method. 
That  neither  of  the  above  methods  of  operating  is  all  that 
can  be  desired  is  sufficiently  attested  by  the  numerous  modi- 
fications which  have  been  introduced. 

To  avoid  the  objection  to  Wolfler's  operation  of  carry- 
ing the  loop  of  bowel  over  the  transverse  colon  and  thereby 
possibly  causing  constriction  of  the  latter,  as  well  as  risking 
the  production  of  a  kink  ^  or  sharp  bend  in  the  former, 
Courvoisier,^  and  later  von  Hacker,^  attached  the  jejunum  to 
the  under  surface  of  the  stomach.  An  opening  was  made  in 
the  transverse  meso-colon  ;  the  loop  of  jejunum  was  brought 
through  and  sutured  to  the  posterior  wall  of  the  stomach. 
To  avoid  any  constricting  effect  of  the  mesenteric  opening, 
von  Hacker  stitched  the  margins  of  the  latter  to  the  stomach. 

The  want  of  a  '  plate  '  which  would  be  always  easily 
obtainable  has  led  to  the  employment  of  materials  requiring 
less  time  for  preparation  than  the  original  bone  plates  of  Senn. 
Dawbarn  "*  suggests  plates  made  of  raw  potatoes  ;  and  in  his 
experiments  he  tried  various  other  vegetables,  as  carrots, 
parsnips,  turnips,  &c.  When  soaked  for  an  hour  or  so  in  warm 
or  tepid  water,  they  become  as  rigid  almost  as  wood.  '  After 
remaining  for  a  few  hours  exposed  to  the  digestive  fluids  of 
either  stomach  or  bowel,  it  [potato]  begins  to  soften,  while 
retaining  its  shape.  At  length  it  is  completely  digested  and 
disappears,  this  occurring  at  a  period  of  time  varying  according 
to  what  part  of  the  alimentary  canal  it  occupies.  But  always 
during  the  first  ten  or  twelve  hours  at  least — the  time  in 
which  most  of  all  we  fear  leakage  at  our  anastomosis — it  holds 
the  peritoneal  surfaces  smoothly  in  contact.' 

Baracz  ^  has  also  successfully  used  plates  made  from  raw 

cabbage  turnip  {Brassica  Najms  var.  rapifera).    The  dimensions 

'  In  a  case  of  Billroth's,  death  resulted  in  ten  days  from  this  cause  ;  and  in  a 
case  of  Kocher's  in  four  days. 

2  Centralblatt  fur  Chirurgie,  1883,  p.  794, 
^  Archiv  fur  kiin.  Chir.  1885,  vol.  xxxii.  p.  616. 
*  Annals  of  Surgery,  1893,  vol.  xvii.  p.  147. 
^  Centralblatt  fiir  Chintrgie,  1892,  p.  575. 


256 


THE    STOMACH 


for  these  plates  are — thickness  0'5  cm.,  length  7*5  cm.,  width 
3*5  cm.,  central  opening  3  cm.  long  and  f  cm.  wide.  With 
similar  plates  Heigl  had  a  case  of  recovery  after  gastro- 
enterostomy. 

The  possibility  of  the  plates  slipping,  so  that  their  orifices 
are  not  exactly  opposite  each  other,  has  led  Littlewood  ^  to  fix 
a  decalcified  bone  cylinder  to  one  of  the  plates,  which  exactly 
fits  the  oval  central  opening.  The  cylinder,  when  the  plates 
are  in  position,  is  made  to  pass  into  the  oval  opening  in  the 
other  plate.     A  similar  plan  is  proposed  by  Jessett.^ 

Among  other  kinds  and  shapes  of  materials  used  to  unite 
the  bowel  to  the  stomach  may  be  mentioned  Murphy's 
Metal  Button,^  which  although  of  too  recent  introduction 
and  too  little  in  use  to  admit  of  any  opinion  being  expressed, 
yet  appears  to  have  the  merit  of  shortening  the  period 
of  operation  beyond  anything  yet  attained.  The  button  con- 
sists of  two  parts  (see  figs.  35  and  36)  which  are  separately 

attached  to  the   stomach   and 
_  the  bowel,  union  being  effected 

[f^  ■*.    f/|wi  »-  l^'^  A 1      ^y  ^^^^  fitting  within  the  other, 

and  so  pressing  the  serous  sur- 
1\  I  ^  Mi  ^^gl^^j  il  faces  together.  In  a  table  pub- 
»i3^  I^^Bi    /     lished    by   Mayo^  in    January 

1895,  eight  cases  are  recorded, 
with  six  successful  results.  (See 
'Operations  upon  the  Intes- 
tines '  for  method  of  using  the 
button.) 

Abbe    has    employed    rings 
made  of  thick  catgut.     Several 
stout  strands  of  gut  are  taken, 
and   by    a   special   method    of 
preparation  formed    into  a  thick   circular   cable ;    these  are 
inserted  respectively  into  the  stomach  and  bowel,  and  approxi- 
mated in  a  similar  way  to  Senn's  plates. 

Brokaw  uses    segmented    rubber    rings.     Four   pieces   of 


Fig.  35. 
Figs.  35  and  36.- 

BUTTON 


Fig.  35  sliowri  male  half  of  button,  which 
has  a  spring  flange  for  keeping  up  pressure 
as  atropliy  proceeds.  The  two  springs 
projecting  through  the  fenestra  in  the 
hollow  stem  act  as  the  male  thread  of  a 
screw  when  the  shank  is  telescoped  within 
the  stem  of  fig.  36  ;  fig.  36  shows  the 
female  half  of  the  button. 


'  Lancet,  1892,  vol.  i.  p,  865. 

^  Surgical  Diseases  of  the  Stomach  and  Intestines,  p.  227. 

3  New  York  Medical  Record,  1892,  vol.  xlli.  p.  665. 

■•  Annals  of  Swfiery,  1895,  vol.  xix.  p.  41. 


GASTRO-ENTEROSTOMY  2r,7 

ordinary  rubber  tubing  are  taken,  about  one-sixteenth  to  one- 
eighth  of  an  inch  in  diameter.  These  are  threaded  through 
and  through  with  catgut,  so  that  a  complete  ring  is  produced. 
They  are  inserted  and  secured  much  in  the  same  way  as  Abbe's 
rings. 

Eobinson  '  has  experimented  successfully  with  raw  hide. 
The  plates  are  '  made  by  shaving  the  hair  from  the  green  hide 
of  an  ox.  Then  cut  the  hide  into  strips  an  inch  wide  and  two 
and  a  half  inches  long.  Perforate  the  plate  by  a  diamond- 
shaped  aperture  (half  an  inch  by  three-quarters  of  an  inch). 
Then  apply  four  to  six  sutures  to  the  plate,  armed  with  four 
to  six  needles,  and  it  is  ready  for  use.' 

The  contraction  of  the  orifice  between  the  two  viscera,  with 
reappearance  of  the  original  symptoms  has  led  to  other  modi- 
fications in  the  formation  of  the  two  visceral  wounds. 

Paul  2  found  that  by  strangulating  the  connecting  surfaces 
of  the  stomach  and  intestine,  an  opening  was  left  after  the 
separation  of  the  slough  which  apparently  showed  no  tendency 
to  contract. 

Postnikow  ^  adopts  a  somewhat  similar  method,  with  the 
exception  that  the  part  strangulated  is  limited  to  the  mucous 
membrane  which  projects  through  a  small  oval,  cut  out  of  the 
visceral  wall  as  far  down  as  the  muscularis  mucosae. 

McGraW*  recommends  a  wound  whose  edges  should  be 
lined  by  mucous  membrane.  By  this  means  the  continuity  of 
the  raw  edge  is  broken.  The  incisions  into  the  viscera  may  be 
crucial,  H-shaped,  or  three-sided.  The  flaps  so  formed  are 
turned  back  and  secured  to  the  serous  surface. 

Results  of  operation. — It  is  impossible,  from  the  compara- 
tively limited  number  of  cases  operated  upon  under  any  one 
of  the  various  methods  of  gastro-enterostomy  above  described, 
to  express  any  opinion  upon  their  relative  merits.  A  true 
criterion  can  only  be  obtained  when  a  sufficient  series  of 
cases  performed  by  one  method  and  by  the  same  surgeon 
has  been  pubhshed.  Until  such  a  series  be  forthcoming, 
surgeons   must  select   from   the   numerous    operations    pro- 

'  New  York  Med.  Journ.  1890,  vol.  lii.  p.  429. 

^  Liverpool  Medico-Chirurgical  Journ.  1892,  vol.  xii.  p.  355, 

3  Centralblaft  fur  Chiriirgie,  1892,  No.  49,  p.  1018. 

*  Annals  of  Surgery,  1893,  vol.  xviii.  p.  313. 

S 


2o8  THE   STOMACH 

posed  that  particular  one  which  appeals  most  to  their  own 
judgment.  Beckoning  under  the  same  head  all  cases  operated 
upon  with  absorbable  plates,  no  matter  what  the  material, 
Magill '  has  collected  sixty-one  cases  with  fourteen  deaths,  a 
mortality  of  22-95  per  cent.,  which  he  states  constitutes  a 
strong  argument  for  this  method  of  operating.  Every  method 
can  claim  a  success,  usually  in  the  hands  of  the  originator  ; 
but  it  is  perhaps  little  known  how  many  failures  have  fallen 
to  the  lot  of  others  who  have  sought  by  that  same  method  to 
achieve  a  like  good  result. 

It  is  well  to  indicate  some  of  the  many  sources  of  failure 
and  troublesome  after  effects  which  are  to  be  met  with  in 
the  adoption  of  almost  every  method. 

(1)  Regurgitation  of  the  contents  of  the  hoivel  into  the  stomach. 
The  effect  of  this  upon  the  patient  is  extremely  distressing. 
Eructations  of  foetid  gas  and  faecal  matter  cause  the  tongue  to 
become  dry  and  brown,  and  the  mouth  very  foul.  Great  relief 
is  obtained  by  freely  washing  out  the  stomach.  This  should 
be  repeated  as  often  as  deemed  necessary.  Barker  found 
benefit  obtained  by  the  administration  of  creasote,  and  from 
placing  the  patient  in  the  semi-recumbent  position,  so  that  the 
ojjening  into  the  bowel  became  dependent. 

(2)  Pain. — Acute  pain  is  sometimes  felt  in  the  region  of 
the  stomach  wound.  At  times  slight,  it  becomes  suddenly 
augmented  by  sharp  stabs  which  cause  the  patient  to  cry  out. 
More  general  pain  over  the  abdomen  indicates  peritonitis. 
Opium  by  the  bowel,  or  morphia  subcutaneously,  should  be 
given. 

(3)  Persistent  vomiting  and  hiccough. — This  sometimes  is 
very  troublesome,  and  if  it  does  not  portend  a  rapidly  fatal 
result  from  peritonitis  or  obstruction,  may  indicate  at  a  later 
period  a  reclosure  of  the  artificial  opening. 

(4)  Suppression  of  urine. — In  one  of  my  cases  this  proved 
absolute.  No  urine  was  passed  from  the  time  of  the  operation 
till  the  patient's  death,  about  four  days  later. 

(5)  Collapse. — In  most  of  the  earlier  cases  collapse  was  one 
of  the  commonest  causes  of  death.  The  patient  rallies  but 
slightly,  if  at  all,  from  the  operation,  and  dies  within  a  few 
hours. 

'  Annala  of  Surgery,  1894,  vol.  xxi.  p.  313. 


G  ASTRO-]i]  NTEROSTOM  Y  259 

(6)  Exhaustion  and  inanition. — Usually  already  in  a  more 
or  less  exhausted  condition  at  the  time  of  the  operation,  the 
patient's  strength  proves  insufficient  to  survive  the  period 
necessary  for  the  proper  healing  of  the  parts  and  the  intro- 
duction of  sufficient  nourishment.  Death  occurs  in  a  few 
days. 

(7)  Hceniorrhage. — In  one  case  subsequent  haemorrhage 
caused  a  fatal  result  on  the  fourth  day.  In  this  instance  no 
vessels  had  been  secured  by  ligature  at  the  time  of  the  opera- 
tion, pressure  alone  was  used.  The  weakness  of  the  patient 
at  the  time  of  the  operation  was  probably  the  cause  of  the 
slight  bleeding,  and  hence  certain  vessels  escaped  observation 
which  would  otherwise  have  been  seen  and  properly  secured. 

(8)  Peritonitis. — Either  as  the  result  of  leakage,  or  ineffici- 
ent '  toilette  '  at  the  time  of  operation,  peritonitis  has  proved  no 
uncommon  cause  of  a  fata,l  result.  Acute  and  general,  it  may 
cause  death  in  twenty-four  hours  ;  or  if  more  localised  and  less 
acute,  a  more  sluggish  purulent  form  may  cause  death  in  a 
few  days. 

(9)  Gastric  fistula. — As  the  result  of  insecure  stitching, 
coupled  also  sometimes  with  violent  vomiting  or  retching,  a 
leakage  takes  place  at  the  line  of  union  of  the  two  viscera.  If 
adhesions  have  sufficiently  formed  between  the  visceral  wound 
and  the  parietes,  the  parietal  wound  gives  way,  and  a  complete 
communication  exists  between  the  stomach  and  the  exterior. 
All  nourishment  given  hy  the  mouth  passes  out  through  the 
fistula,  and  the  patient  dies  of  inanition. 

(10)  Intestinal  obstruction, — Obstruction  in  the  bowel  may 
arise  from  one  of  two  causes.  Either  as  the  result  of  some 
obstruction  in  the  bowel  itself,  from  impaction  of  the  plates 
used  for  coapting  the  visceral  surfaces,  or  from  a  kinking  or 
constriction  of  the  part.  In  two  at  least  recorded  cases  death 
has  been  caused  by  the  bowel  kinking  just  beyond  its  point  of 
union  with  the  stomach.^  The  bowel  falling  sharply  away  from 
its  sutured  surface  forms  a  bend  which  efficiently  stops  any 
onward  passage  of  the  contents  of  the  stomach.  Any  suspicion 
of  such  an  accident  should  be  treated  by  turning  the  patient 
on  to  the  right  side,  or  even  into  a  semi-recumbent  position. 
Constriction  of  the  bowel  may  occur  at   the  opening  made 

'  See  page  '255,  footnote. 


i>60  THE    STOMACH 

in  the  meso-colon  to  pass  the  jejunum  through  before  uniting 
it  to  the  posterior  wall  of  the  stomach.  Obstruction  in  the 
transverse  colon  may  be  produced  by  the  loop  of  intestine  which 
is  carried  over  it  to  be  stitched  to  the  anterior  wall  of  the 
stomach, 

(11)  Subsequent  closure  of  the  himucous  fistula. — The  recur- 
rence of  symptoms  some  weeks  or  months  afterwards  may 
mdicate  the  contraction  or  closure  of  the  communication 
between  the  stomach  and  the  bowel.  In  a  case  of  Stansfield's,' 
in  which  Senn's  plates  were  used,  symptoms  returned  two 
months  after  the  ojDeration.  On  the  death  of  the  patient  two 
months  later,  the  orifice  was  found  completel}^  closed.  In  a 
case  of  Larkin's,-  where  Senn's  plates  were  also  used,  the 
symptoms  returned  in  eight  weeks.  "W^en  the  patient  died 
about  five  months  after  the  operation,  the  opening  was  found 
completely  closed.  In  a  case  by  Keen,^  in  which  Murphy's 
button  was  used,  the  opening  was  found,  forty-seven  days  after 
the  operation,  to  have  diminished  to  one-half  the  original  size. 

(12)  Openmg  the  ileum  in  place  of  the  jejunum. — In  more 
than  one  instance  this  mistake  has  been  made  at  the 
operation.  Lauenstein  records  having  united  the  ileum  to 
the  stomach  at  a  point  sixteen  iaches  from  the  ileo-caecal 
valve.  The  error  is  subsequently  detected  by  the  passage 
j)er  rectum  of  food  in  a  practically  unchauged  condition. 
Death  occurs,  as  in  gastric  fistula,  from  inanition. 

(13)  Pneumonia. — Czerny  records  two  deaths  from  pneu- 
monia. 


CHAPTEE   XXX 

ovERATiojJi-.  (continued)  :     pylorectomy  ;     pyloroplasty; 

PYLORIC    DIVULSION,    AND  CURETTING  (bERNAYS) 

9.  Pylorectomy. — The  operation  consists  in  total  extirpation 
of  the  pylorus,  together  with  the  disease  which  implicates  it. 
It  therefore  frequently  embraces  a  considerable  portion  of  the 
pyloric  end  of  the  stomach,  as  well  as — in  exceptional  instances 

'  Brit.  Med.  Jo7trn.  1890,  vol.  i.  pp.  294,  1300. 

-  Lancet,  1891,  vol.  ii.  p.  1222. 

^  McGraw,  Annals  of  .Kjirgerij,  1893,  vol.  sviii.  p.  313. 


PYLORECTOMY  261 

— a  portion  of  the  first  part  of  the  duodenum.  The  duodenum 
is  then  stitched  to  the  stomach. 

The  preparation  of  the  patient  is  in  every  respect  similar 
to  what  has  ah-eady  been  described  in  the  preceding  opera- 
tions.    (See  page  215.) 

The  skin  incision,  from  four  to  five  inches  in  length,  is 
made  either  in  the  median  line  above  the  umbilicus,  or 
obliquely  downwards  from  left  to  right,  commencing  an  inch 
and  a  half  or  so  to  the  left  of  the  median  line,  and  carried 
about  the  same  distance  above  the  umbilicus.  In  the  only 
instance  in  which  I  performed  this  operation  I  used  the 
oblique,  and  on  the  only  occasion  on  which  I  assisted  another 
surgeon,  the  median  was  employed.  In  both  cases  equally 
ready  access  was  obtained  to  the  parts  required  for  operation. 
Other  incisions  have  been  employed,  such  as  transverse  and 
crucial.  Both,  however,  should  the  patient  recover,  would 
tend  to  favour  the  subsequent  development  of  a  ventral  hernia, 
owing  to  the  weakening  effect  produced  by  a  too  free  division 
of  muscle  fibres. 

As  soon  as  the  abdomen  is  opened,  the  fore  and  middle 
fingers  of  the  right  hand  are  introduced  to  ascertain  the 
condition  of  the  tumour  with  regard  to  its  size,  freedom  from 
adhesions,  and  extent  of  involvement  of  stomach,  duodenum, 
and  omenta,  and  also  the  existence  or  not  of  enlarged 
lymphatic  glands.  A  few  sponges  or  cloths  secured  with  long 
pieces  of  silk  are  placed  within  the  abdomen  for  protective 
purposes.  The  small  omentum  above  is  first  severed  from  its 
connections  with  the  upper  border  of  the  part  to  be  removed. 
This  is  best  effected  by  using  an  aneurysm  needle  threaded  with 
gut  or  silk,  and  made  to  take  up  small  portions  of  the  omentum. 
^  double  ligature  is  passed,  and  the  strand  with  its  contained 
vessels  divided  between  the  two  ligatures.  When  sufficiently 
freed,  the  forefinger  of  the  right  hand  can  be  passed  beneath 
the  tumour  and  made  to  push  its  way  at  various  points 
through  the  gastro-colic  omentum  close  to  its  upper  attach- 
ment, the  membrane  itself  being  severed  in  a  similar  way  to  the 
lesser  omentum.  I  found  this  a  very  easy,  rapid,  and  secure 
way  of  dealing  with  the  lower  omentum.  The  tumour  thus 
freed  from  all  attachments  is  brought  out  of  the  abdomen  and 
a  large  flat  sponge  or  cloth  placed  beneath  it,  to  protect  the 


262  THE    STOMACH 

abdominal  cavity  from  contamination  from  either  the  gastric 
contents  or  other  external  sources.  At  this  stage  enlarged 
lymphatic  glands  should  be  removed. 

The  next  stage  of  the  operation,  or  as  it  is  sometimes 
termed  the  third  stage,  consists  in  the  removal  of  the  diseased 
parts. 

By  means  of  a  pair  of  scissors  the  duodenum  is  first  cut 
through  just  beyond  the  pylorus.  To  prevent  any  escape 
from  either  end  of  the  divided  bowel,  each  portion  is  taken 
charge  of  by  a  separate  assistant.  As  soon  as  the  division  is 
effected  and  all  bleeding  points  secured,  the  duodenum  is 
either  clamped,  or  tied  round  with  a  piece  of  rubber  tubing. 
In  some  instances  it  is  sufficient  to  stuff  a  piece  of  sponge  or 
lint  into  the  canal.  In  place  of  an  assistant  to  take  charge  of 
the  duodenum,  it  may  be  clamped  or  tied  prior  to  division.  The 
surgeon  next  turns  his  attention  to  the  stomach.  The  cut  in 
this  viscus  depends  to  some  extent  upon  the  manner  in  which, 
in  cases  of  carcinoma,  the  growth  has  involved  the  organ. 
Where  a  choice  exists,  it  is  usual  to  cut  with  the  scissors 
obliquely  downwards  from  the  lesser  curvature  to  the  right, 
keeping  well  free  of  the  tumour.  In  cases  where  the  growth 
extends  more  along  the  greater  curvature,  the  direction  of 
the  incision  is  reversed,  passing  obliquely  upwards  from  the 
greater  curvature  to  the  right.  Where  both  curvatures  are  freer 
than  the  intermediate  part,  the  two  oblique  cuts  are  made 
with  a  vertical  one  joining  both.  To  this  central  vertical  part 
the  duodenum  is  attached.  In  the  other  two  instances  it  is 
usual  to  attach  the  duodenum  to  the  greater  curvature.  When 
united  to  the  lesser,  a  very  ugly-shaped  cul-de-sac  is  left ; 
which  is  all  the  more  marked  if  there  is  any  dilatation  of  the 
stomach.  The  assistant,  with  the  stomach  grasped  near  the 
tumour,  between  the  thumbs  and  fingers  of  both  hands, 
everts  the  pyloric  orifice,  so  that  as  the  surgeon  cuts  through 
the  stomach,  nothing  is  permitted  to  escape  from  it.  The 
division  of  the  part  need  only  be  completed  to  within  an  inch 
or  so  of  either  curvature.  Before  complete  severance  of  the 
tumour  and  after  all  vessels  have  been  secured,  the  open  part 
of  the  stomach  may  be  closed  by  a  series  of  interrupted 
Lembert  stitches,  or  by  a  continuous  suture.  In  the  former 
case  the  stitches  should  all  be  left  long,  their  free  ends  being 


PYLORECTOMY  2C3 

caught  up  together  with  a  pair  of  forcipressure  forceps.  The 
advantage  of  this  is,  that  by  pulHng  on  the  stitches  some 
manipulation  of  the  part  is  made  possible  while  effecting  union 
with  the  duodenum. 

After  completing  the  section  and  securing  any  further 
bleeding  points,  the  duodenum  is  applied  to  the  orifice  in  the 
stomach.  Stitching  is  commenced  by  uniting  the  posterior 
margin  of  the  orifices  first.  This  is  effected  from  within, 
sutures  being  passed  by  a  small  curved  needle  with  needle- 
holder  and  made  to  pick  up  and  unite  together  the  mucous 
membrane.  As  described  by  Jacobson  ^ — '  They  are  passed 
first  at  the  cut  edge  of  the  stomach  between  the  mucous  and 
muscular  coats,  carried  on  between  the  muscular  and  serous, 
then  through  the  same  layers  of  the  duodenum,  and  finally 
brought  out  between  these  layers  and  the  mucous  membrane 
at  the  cut  edge  of  the  duodenum.  When  the  posterior  aspect 
of  the  two  viscera  is  thus  soundly  closed,  the  anterior  one  is 
united  by  Lembert's  suture.  If  the  cut  mucous  membranes 
do  not  come  accurately  together,  a  few  sutures  may  be  put  in 
here  separately  from  within.  Care  must  be  taken  in  inserting 
the  sutures  to  avoid  the  formation  of  folds  (Billroth).'  A 
weak  point  in  the  line  of  suture  is  at  the  angle  of  closure  of 
the  stomach.  This  should  be  particularly  looked  to  before 
returning  the  parts. 

At  the  completion  of  the  union  of  the  two  viscera,  a  few 
stitches  should  be  inserted  to  unite  the  edges  of  the  severed 
omenta  to  the  upper  and  lower  borders  of  the  newly  formed 
parts. 

The  sponges  or  cloths  are  finally  removed,  the  wound 
itself  being  carefully  cleansed  before  dropping  the  parts  back 
into  the  abdominal  cavity. 

Two  very  important  modifications  of  the  operation,  serving 
to  shorten  the  time  of  its  performance,  have  been  successfully 
carried  out,  making  use  of  Senn's  plates  and  Murphy's 
buttons  -  for  the  union  of  the  two  viscera,  much  in  the  same 
way  as  they  are  employed  in  gastro-enterostomy. 

Eawdon  ^  thus  describes  the  operation  as  performed  by  him 
with  Senn's  plates :  '  The   stomach  wound  was   closed  with 

'  Ojperations  of  Surgery,  p.  782.  -  Lancet,  1895,  vol.  i.  p.  304J 

Brit.  Med.  Joiirn.  1890,  vol.  1.  p.  323. 


264  THE    STOMACH 

continuous  sutures  of  fine  silk,  except  one  inch  at  the  greater 
curvature,  which  was  left  open  to  admit  of  the  introduction 
of  one  of  Dr.  Senn's  plates  of  decalcified  bone.  A  second 
plate,  cut  circular,  was  passed  into  the  duodenum  and  placed 
so  as  to  lie  across  it  with  the  coats  of  the  bowel  overlapping 
the  plate.  The  openings  in  the  stomach  and  duodenum  were 
now  brought  into  apposition,  and  the  corresponding  ligatures 
on  the  two  plates  tied  together,  so  that  direct  communication 
was  established  between  the  two  viscera.  The  parts  were 
returned  into  the  abdomen,  and  the  wound  closed  in  the 
usual  way.     The  operation  was  completed  in  less  than  an  hour.' 

The  possibility  of  completing  such  an  operation  in  so 
short  a  time  as  an  hour  must  be  considered  a  great  advance 
upon  what  has  hitherto  occupied  nearer  three  hours.  The 
use  of  plates  can,  however,  only  be  possible  when  the 
duodenum  is  sufficiently  long  and  moveable  to  allow  of  their 
being  coapted  without  tension.  The  necessary  overlapping  of 
the  plate  by  the  bowel  naturally  requires  a  greater  length  of  the 
latter  than  in  the  case  of  simple  suture,  so  that  it  is  a  method 
which  cannot  be  applied  in  every  instance  of  excision.  For  the 
same  reason  Murphy's  button  may  not  always  be  applicable. 

The  after  treatment  of  the  case  is  essentially  the  same  as 
in  other  operations  upon  the  stomach  (see  page  216) .  The  great 
length  of  time  which  the  operation  has  usually  taken  renders 
the  factor  of  shock  a  very  serious  one ;  every  care  therefore 
must  be  taken  to  tide  the  patient  over  the  first  few  hours 
after  the  operation. 

Results  of  oj)eration. — In  by  far  the  largest  number  of 
cases  where  death  has  followed  the  operation,  it  has  been  due 
to  shock.  In  a  considerable  proportion  perforative  peritonitis 
has  led  to  a  fatal  result.  In  Eiselsberg's  ^  record  of  nineteen 
cases  taken  from  Billroth's  clinic  between  March  1885  and 
October  1889,  there  were  ten  fatal  cases.  Of  these,  seven  were 
due  to  perforative  peritonitis,  one  to  haemorrhage  from  the 
pancreas,  and  two  apparently  from  shock.  In  this  country 
most  of  the  fatal  results  have  been  due  to  shock,  death  usually 
occurring  within  a  comparatively  few  hours  after  the  opera- 
tion. The  severance  of  the  omentum  from  the  greater  curva- 
tiu-e  has  been  known  to  cause  gangrene  of  the  colon. 

'  Ardiivfur  klin.  Chir.  1890,  p.  785. 


rYLORorLAS'r>'  205 

The  combined  operation  of  pylorectomy  and  gastro-entero- 
stomy. — This  operation  consists  in  the  excision  of  the  pylorus 
with  the  affected  parts  ;  complete  occlusion  of  both  bowel  and 
stomach,  and  union  of  the  jejunum  with  the  latter. 

The  earlier  stages  of  the  operation  are  in  all  respects 
similar  to  those  of  pylorectomy  up  to  the  point  where  the 
tumour  has  been  freed  from  its  omental  attachments  and 
brought  out  of  the  abdomen.  While  the  stomach  is  secured 
by  the  hand  of  the  assistant,  the  surgeon  proceeds  to  cut  with 
scissors  completely  through  the  viscus  beyond  the  affected 
part.  The  duodenum  with  the  attached  growth  is  turned 
aside  outside  the  abdomen,  and  any  escape  from  the  internal 
parts  prevented  by  the  application  of  clamp  forceps.  The 
bleeding  points  in  the  edges  of  the  divided  stomach  wall  being 
secured,  a  continuous  suture  of  fine  silk  or  chromicised  gut  is 
made  to  occlude  the  gastric  cavity  by  passing  through  the 
entire  thickness  of  the  stomach  coats.  A  second  line  of 
sutures  is  then  made,  in  order  to  bring  the  serous  surfaces 
well  and  securely  into  contact.  This  may  be  effected  either 
by  a  series  of  Lembert's  or  by  quilt  sutures.  The  stomach  is 
then  dropped  back  for  the  time  being  into  the  abdomen. 

The  tumour  is  next  severed  from  its  attachments  to  the 
duodenum.  A  clamp  or  rubber  band  is  made  to  embrace  the 
duodenum  outside  the  point  where  the  division  of  the  gut 
takes  place.  The  orifice  of  the  bowel  is  then  closed  in  the 
same  way  as  that  of  the  stomach,  and  when  completed  and 
cleansed  dropped  back  into  the  peritoneal  cavity,  after 
removal  of  the  clamp. 

The  stomach  is  again  brought  out  of  the  wound,  and  the 
operation  of  gastro-enterostomy  proceeded  with  as  already 
described. 

Tuholske  '  has  performed  the  combined  operation  success- 
fully in  the  reverse  way.  He  first  performed  gastro-entero- 
stomy, and  later  removed  the  diseased  part. 

10.  Pyloroplasty,  or  Heineke-Mikulicz  operation. — The  opera- 
tion consists  in  dividing  the  strietured  pylorus  much  in  the  same 
way  as  an  urethral  stricture  is  treated  by  external  urethrotomy, 
but  in  addition,  the  wound  so  formed  is  reunited  in  the  oppo- 
site axis  to  that  in  which   the  original   cut    is   made.     The 

'  Annual  of  the  Universal  Medical  Sciences,  1884,  vol.  iii.  C  — 16. 


266 


THE    STOMACH 


patient  is  prepared  in  the  usual  way  for  operations  upon  the 
stomach.     (See  page  215.) 

The  skin  incision  adopted  by  Mikulicz  ^  is  four  inches  in 
length,  running  parallel  with  and  about  two  inches  from  the 
left  costal  arch.  Heineke  opens  the  abdomen  in  the  linea 
alba.  After  opening  the  abdominal  cavity,  the  anterior  wall 
of  the  usually  dilated  stomach  is  sought  for  and  withdrawn 
out  of  the  parietal  wound.  The  parts  beneath  are  protected 
with  sponges  or  cloths. 


Fig  3  . 


fiG.  38. 


Fig.  39.  Fig.  40. 

Figs.  37-40. — Hkineke-Mikulicz  Operation  of  Pyloroplasty 

Fig.  37  shows  line  of  incision  through  constricted  pylorus  ;  fig.  38  shows  the  appearance  of  the 
parts  after  division  of  the  stricture ;  fig.  39  shows  method  of  suturing  the  wound ;  fig.  40 
shows  the  suturing  completed 


A  small  longitudinal  incision  is  made  in  the  anterior  wall 
of  the  stomach  just  at  the  boundary  of  the  pylorus,  of  suffi- 
cient size  to  admit  the  finger.  The  contracted  orifice  is 
sought  for  by  the  index  finger  of  the  right  hand,  which  serves 
as  a  guide  for  the  passage  of  a  director  through  the  stricture 
into  the  duodenum. 

By  means  of  a  blunt-pointed  bistoury  the  pylorus  is  com- 
pletely divided.     Such  bleeding  points  as  need  securing  are 

'  Archiv  fur  klin.  Chir.  1888,  Bd.  xxxvii.  p.  84. 


1)IVULS[0X   OF   THE   PYLOllUS  '267 

lipjatured.  The  longitudinal  incision  is  then  converted  into  a 
transverse  wound  by  a  double  series  of  sutures,  so  applied  as 
when  tightened  to  bring  the  most  distant  points  together, 
and  make  the  middle  of  the  two  edges  the  most  distant  points 
of  the  new  wound  (see  figs.  37-40).  The  parts  are  then 
returned,  and  the  parietal  wound  closed  and  dressed  in  the 
usual  way. 

11.  Digital  divulsion  of  the  pylorus,  or  Loreta's  operation. — 
This  operation  consists  in  first  performing  gastrotomy,  and 
then  forcibly  dilating  the  orifice  of  the  pylorus  with  the 
fingers. 

The  preparation  of  the  patient  is  the  same  as  already  de- 
scribed for  other  operations  upon  the  stomach  (see  page  230)  ; 
and  the  first  stage  of  the  operation,  which  consists  in  bring- 
ing the  duodenum  outside  the  abdominal  wound,  is  performed 
in  a  similar  way  to  that  in  pylorectomy,  with  the  exception 
that  the  omenta  are  not  severed  from  the  upper  and  lower 
margins. 

The  operation  as  performed  is  thus  described  by  Holmes.^ 
*  After  opening  the  abdomen  on  the  right  of  the  middle  line 
and  separating  any  adhesions  of  the  pylorus  to  the  neighbour- 
ing parts,  the  stomach  is  drawn  out  of  the  wound  as  far  as 
necessary.  The  coats  of  the  stomach  are  then  lifted  up  in  a 
transverse  fold,  and  a  cut  made  through  them  with  strong 
scissors  midway  between  the  two  curvatures  and  a  little  more 
than  an  inch  from  the  pylorus.  This,  however,  may  need  to 
be  enlarged.  Any  bleeding  in  the  incision  must  be  stopped 
by  ligatures.  The  right  forefinger  is  then  introduced  and  the 
pylorus  examined.  To  commence  dilatation  by  forcing  in  the 
finger,  the  left  finger  must  also  be  introduced  in  order  to 
steady  the  pylorus.  Once  the  right  finger  is  through,  the 
pylorus  is  hooked  down  towards  the  abdominal  wound,  a 
manoeuvre  which  may  enable  the  operator  to  get  the  left  index 
finger  also  through  the  pylorus.  Considerable  and  prolonged 
force  may  be  required  to  eflect  sufficient  dilatation,  owing  to 
the  powerful  reflex  contraction  of  the  sphincter  muscle.  In 
Loreta's  case  it  is  reported  that  the  observers  noted  that  one 
finger  was  separated  more  than  three  inches  from  the  other. 
The  gastric   wound   is   then  closed   and   returned   into   the 

'.  Brit.  Med.  Journ.  1685,  vol.  i.  p.  372. 


268  THE    STOMACH 

abdominal  cavity.  The  parietal  wound  is  stitched  and  the 
usual  antiseptic  dressings  applied.  If  considered  advisable, 
nourishment  may  be  given  by  the  mouth  a  few  hours  after 
the  operation.' 

In  a  case  successfully  operated  upon  by  Treves,'  an 
incision  four  inches  ill  length  was  made  in  the  linea  alba, 
above  the  umbilicus.  The  attachments  were  so  considerable 
that  the  parts  could  not  be  withdrawn.  The  stomach  was 
opened  by  a  vertical  incision  midway  between  the  two  curva- 
tures and  about  two  inches  from  the  pyloric  orifice.  The 
object  of  the  vertical  cut  and  the  greater  distance  from  the 
pylorus  was  to  avoid  dividing  large  vessels.  The  gastric 
incision  was  closed  by  continuous  silk  suture  through  mucous 
and  muscular  coats,  and  Lembert  sutures  through  the  serous 
coat. 

Results  of  ojjeration. — Simple  as  the  operation  appears,  it 
is  far  from  being  devoid  of  very  grave  consequences.  With 
less  stretching  than  that  successfully  exercised  by  Loreta, 
the  wall  of  the  stomach  has  been  ruptured,  death  resulting 
in  four  hours.  The  orifice  may  recontract  or  become  ob- 
structed, and  the  symptoms  return  as  early  as  the  fifth  day. 
Both  such  results  occurred  in  cases  reported  by  Swain.^ 
Considerable  haemorrhage  may  result,  the  bleeding  taking 
place  freely  into  the  stomach.  (For  further  remarks  upon  the 
operation,  see  page  222.) 

12.  Curetting  the  pylorus,  or  Bernays's  operation. — The 
operation  consists  in  first  performing  gastrostomy  and  curet- 
ting or  scraping  away  that  portion  of  the  growth  which  ob- 
structs the  pyloric  orifice. 

The  operation  as  successfully  performed  by  Bernays  ^  was 
thus  carried  out :  After  the  usual  preparations,  gastrostomy  was 
performed.  The  stomach  was  first  washed  out  with  warm  water. 
Then  the  finger  was  introduced,  and  a  considerable  quantity  of 
the  tumour  removed  by  it.  *  By  means  of  the  largest  sizes  of 
Simon's  sharp  spoons  I  scooped  out  all  the  soft  masses  until 
a  grating  noise  was  produced  by  the  instruments  against  the 
indurated  base  of  the  tumour.  ...  A  current  of  cold  carbolised 

'  Brit.  Med.  Journ.  1889,  vol.  i.  p.  1105. 

2  Lancet,  1892,  vol.  i.  p.  87. 

'  Annals  of  Surgery,  1887,  vol.  vi.  p.  4-i9. 


CXTtETTING  269 

water  was  next  turned  into  the  stomach  and  was  allowed  to 
run  until  the  fluid  returned  clear.'  The  operation  lasted  an 
hour  and  a  half.  The  masses  removed  weighed  fourteen 
ounces.  About  nine  hours  after  the  operation  the  patient 
drank  a  glass  of  milk,  which  he  retained,  and  although  more 
was  subsequently  taken,  nothing  came  out  through  the 
abdominal  wound.  Some  leakage,  however,  took  place  on  the 
fifth  day,  and  henceforward  unless  the  patient  took  some 
precautions  with  regard  to  his  food.  Two  months  after,  the 
fistula  was  closed.  A  month  later,  however,  it  had  to  be  re- 
opened in  order  to  rescrape,  which  was  also  accomplished 
successfully.  In  the  second  case  successfully  operated  upon 
by  Bernays,  much  the  same  method  of  procedure  was  adopted  ; 
but  the  tumour  was  much  smaller,  and  the  amount  removed 
only  weighed  fourteen  drachms. 

In  his  remarks  upon  these  two  cases,  the  author  advises 
strongly  against  the  performance  of  gastrotomy  and  the  return 
of  the  stomach.  Obstruction  is  certain  to  recur,  and  a  per- 
manent orifice  is  necessary  in  order  to  repeat  the  curetting. 

For  the  prognosis  in  respect  to  the  operations  described  in 
this  chapter  when  adopted  for  obstructions  at  the  pylorus, 
see  Chapter  XXVI,  p.  218. 


PAET   III 

THE  SMALL  AND  LARGE  INTESTINE 


SECTION  I 

THE  DUODENUM 

CHAPTEE  XXXI 

ANATOMY.     INJURIES  :    RUPTURE  ;    FOREIGN     BODIES 

Anatomy. — The  duodenum,  so  called  from  its  length,  being 
about  equal  to  the  breadth  of  twelve  fingers — that  is,  from 
ten  to  twelve  inches — forms  the  upper  of  the  three  por- 
Uons  into  which  the  small  intestine  is  arbitrarily  divided. 
It  is  the  widest  part  of  the  small  bowel,  varying  in  diameter 
from  an  inch  and  a  half  to  two  inches,  and  takes  a  course 
which  may  roughly  be  described  as  horseshoe  in  shape,  with 
the  convexity  of  the  curve  to  the  right. 

Commencing  at  the  pylorus,  it  is  directed  slightly  upwards 
and  backwards  to  the  right  to  the  neck  of  the  gall  bladder.  It 
measures  about  two  and  a  half  inches  in  length,  and  consti- 
tutes the  first  or  superior  portion.  Its  relations  are — in  front 
and  above,  to  the  liver  and  gall  bladder  ;  behind,  it  has  the  gall 
duct  and  the  hepatic  vessels.  It  is  entirely  surrounded  by 
peritoneum. 

The  second  or  descending  portion  extends  from  the  neck 
of  the  gall  bladder  downwards  to  the  body  of  the  third  lumbar 
vertebra.  It  is  in  contact  in  front  with  the  transverse  colon 
and  meso-colon.  Behind,  it  is  connected  by  areolar  tissue  with 
the  right  kidney  and  the  vertebral  column.  To  the  left  is 
the  head  of  the  pancreas.  Descending  behind  the  left  border 
of  the  gut  is  the  common  l>ile  duct,  which  together  with  the 


272  THE  DUODENUM 

pancreatic  duct  perforate  obliquely  the  walls  of  the  bowel  and 
open,  by  a  common  orifice  into  its  interior,  at  a  point  about 
four  inches  from  the  pylorus.  It  is  covered  by  peritoneum 
only  on  the  anterior  surface. 

The  third,  transverse  or  oblique,  portion  extends  to  the 
left,  ascending  slightly  from  the  right  side  of  the  body  of  the 
third  lumbar  vertebra  to  the  left  side  of  the  second.  Here  it 
terminates  by  forming  an  abrupt  angle  with  the  commence- 
ment of  the  jejunum.  In  front  and  passing  over  the  upper 
border  are  the  superior  mesenteric  vessels.  Behind  are  the 
aorta,  inferior  vena  cava,  and  pillars  of  the  diaphragm. 

The  mesentery  commences  where  the  duodenum  becomes 
continuous  with  the  jejunum.  A  notch,  which  can  be  felt  in 
the  peritoneum,  serves  as  a  guide  to  this  particular  part. 

The  part  of  the  duodenum,  about  an  inch  long,  which 
extends  along  the  side  of  the  left  crus  of  the  diaphragm 
opposite  the  second  lumbar  vertebra  is  sometimes  termed  the 
fourth,  or  second  ascending,  portion.  It  is  firmly  fixed  to  the 
front  of  the  aorta  and  the  crus  of  the  diaphragm  by  a  strong 
fibro-muscular  band  which  has  been  termed  the  *  musculus 
suspensorius  duodeni.'  By  means  of  this  ligamentous  band 
the  duodenum  is  held  up  as  by  a  sling,  and  kept  constantly  in 
position  (Treves). 

In  relation  to  the  surface  of  the  body,  the  duodenum 
occupies  the  right  hypochondriac,  right  lumbar,  and  unabilical 
regions.  On  the  right  side,  a  little  below  the  ninth  rib,  the 
hepatic  flexure  of  the  colon  lies  in  front.  A  point  about  an 
inch  above  the  umbilicus  marks  the  place  at  which  the  trans- 
verse portion  crosses  the  spinal  column.  Behind,  the  spine 
of  the  second  lumbar  vertebra  is  just  above  the  duodenum. 

In  its  minute  structure  the  duodenum  resembles  the  other 
parts  of  the  intestine.  Of  the  four  coats — serous,  muscular, 
submucous,  and  mucous — the  first,  as  already  indicated,  only 
surrounds  the  bowel  to  a  limited  extent.  As  regards  the 
mucous  membrane,  valvules  conniventes  begin  to  appear  a 
short  distance  from  the  pylorus,  and  become  very  large  in 
size  just  beyond  the  orifice  of  the  bile  and  pancreatic  ducts. 
Villi  are  present  in  abundance  throughout.  The  crypts  of 
Lieberkuhn  are  also  found  in  its  whole  extent ;  and  Briin- 
ner's  olaiids,  which  are  universally  present,  are  found  most 


INJURIES  273 

abundantly  a  little  way  from  the  pylorus.  The  solitary  glands 
exist  throughout,  but  the  agminated  glands  or  Peyer's  patches 
are  only  occasionally  met  with  in  the  lower  part.  The  cells 
whi(  h  line  the  surface  of  the  mucous  membrane  are  of  the 
columnar  type. 

The  arteries  supplying  the  part  come  from  the  pancreatico- 
duodenalis  superior,  a  branch  of  the  gastro-duodenalis,  itself 
a  branch  of  the  hepatic  ;  and  from  the  pancreatico-duodenalis 
inferior,  a  branch  of  the  superior  mesenteric.  These  two 
arteries  form  a  partial  circle  on  its  concave  border,  coursing 
between  the  duodenum  and  the  pancreas.  The  further  distri- 
bution of  the  vessels  resembles  that  of  other  parts  of  the  small 
intestine,  and  will,  together  with  the  lymphatic  and  nerve 
supply,  be  described  when  dealing  with  the  minute  anatomy 
of  those  parts. 

Injuries. — The  deep  situation  of  the  duodenum  renders  it 
comparatively  secure  against  injury.  Its  fixed  position,  how- 
ever, renders  it  less  likely.to  escape  than  if,  like  other  portions 
of  the  small  bowel,  it  were  freely  movable. 

While  it  may  be  injured  by  bullet  or  shot,  or  by  stabs  or 
sword  thrusts,  such  wounds  are  always  associated  with  similar 
injury  to  the  overlying  parts.  The  only  injury  which,  it 
appears,  may  limit  itself  solely  to  the  duodenum,  is  rupture 
produced  by  a  direct  blow  or  a  squeeze  upon  the  part. 

Ruptiure. — It  is  perhaps  doubtful  whether  rupture  of  the 
duodenum  is  of  such  frequent  occurrence  as  alleged  by  Erich- 
sen,^  who  appears  to  base  his  statement  rather  upon  the  sup- 
position that  it  must  be  so  from  the  anatomically  fixed 
position  of  the  part  than  from  actual  experience.  Most 
authors  speak  of  the  accident  as  an  extremely  rare  one. 
Poland  ^  collected  a  series  of  forty  cases  of  rupture  of  the 
small  intestine,  only  four  of  which  occurred  in  the  duodenum. 
Of  cases  reported  within  the  last  few  years,  I  have  only  been 
able  to  find  five. 

Symptoms. — There  are  no  symptoms  special  to  the  injury  ; 
such  as  do  appear  are  variable  and  indistinguishable  from 
those  which  arise  from  rupture  of  the  small  bowel  elsewhere. 
The  patient  immediately  on  receipt  of  the  injury  complains 

'  Science  and  Art  of  Surgery,  9th  edit.  vol.  i.  p.  877. 
'^  Giii/s  Hospital  Reports,  3rcl  series,  vol.  iv.  p.  142. 


274:  THE   DUODENUM 

of  pain  more  or  less  intense  and  continuous.  Usually  it  is 
felt  in  the  epigastric  region,  but  sometimes  in  other  parts. 
In  a  case  reported  by  Yarr/  pain  was  limited  to  the  supra- 
pubic region  ;  while  in  a  case  reported  by  Heelis  ^  it  was  just 
above  the  right  groin.  The  amount  of  shock  which  follows 
varies.  When  the  injury  is  produced  by  a  sharp  blow,  the 
resulting  shock  appears  to  be  more  marked  than  when  it 
follows  upon  a  severe  squeeze.  Physical  examination  of  the 
abdomen  may  reveal  but  little.  The  skin  is  usually  intact, 
and  manipulation  of  the  belly  may  or  may  not  elicit  tender- 
ness. In  a  case  reported  by  Freeman,^  where  the  patient  was 
kicked  in  the  abdomen  by  a  mule,  and  an  opening  was  found 
at  the  post  mortem  in  the  anterior  surface  of  the  duodenum 
about  an  inch  in  diameter,  no  tender  spot  could  be  detected, 
nor  was  there  any  trace  of  external  injur3^ 

Vomiting  usually  takes  place  at  some  period  after  the 
injury,  and  as  a  rule  the  vomit  does  not  contain  blood.  If 
death  does  not  result  from  the  primary  shock,  the  patient 
generally  rallies  for  a  time,  but  sinks  sooner  or  later  in  a 
condition  of  collapse.  In  a  case  reported  by  Collier,*  the 
secondary  collapse  appeared  thirteen  hours  after  the  injury, 
when  the  patient  died.  In  another  case,  reported  by  Hutchin- 
son,^ the  patient  lived  sixteen  days. 

The  symptoms  which  develop  later  are  those  referable  to 
general  peritonitis. 

As  regards  the  seat  and  nature  of  the  rupture,  the  most 
frequently  injured  part  is  the  lower  half,  that  is  to  say,  the 
part  which  is  most  fixed  ;  and  the  lesion,  which  is  usually  on 
the  anterior  surface,  varies  from  what  is  a  comparatively  small 
perforation  to  a  complete  severance  of  the  entire  circum- 
ference. In  Yarr's  case  the  rupture  was  about  the  size  of  a  six- 
penny piece,  while  in  Heelis's,  two-thirds  of  the  circumference 
was  torn  through  at  the  junction  of  the  second  and  third 
portions  on  the  right  side  of  the  second  lumbar  vertebra ;  and 
in  Collier's  a  complete  separation  had  taken  place  where  the 
bowel  crosses  the  second  lumbar  vertebra. 

'  Brit.  Med.  Journ.  1890,  vol.  i.  p.  1131. 
2  Lancet,  1892,  vol.  i.  p.  191. 
'  Brit.  Med.  Journ.  1889,  vol.  i.  p.  945. 
*  Loud.  Med,  Gazette,  1833,  vol.  xii.  p.  766. 
^  Archives  of  Surgery,  1891,  vol.  iii.  p.  97. 


RUPTURE  £'76 

Treatment. — While  all  the  ordinarymea  iure  s  are  being 
adopted  to  secure  rest  and  relief  of  pain  and  shock,  the  chief 
consideration  centres  upon  the  question  of  operative  inter- 
ference. Whatever  arguments  are  used  for  or  against  an 
exploratory  operation  in  cases  of  rupture  in  other  parts  of 
the  bowel  must  apply  here,  for  the  very  reason  that  it  is 
usually  impossible  to  diagnose  rupture  of  the  duodenum 
from  rupture  elsewhere.  Hence,  as  no  question  can  be 
raised  as  to  the  advantage  of  opening  the  abdomen  in 
cases  of  rupture,  for  instance,  of  the  jejunum,  none  can  be 
entertained  with  regard  to  a  like  injury  to  the  duodenum. 
If  it  should  ever  prove  possible  to  diagnose  with  any  degree 
of  certainty  such  a  lesion  as  here  discussed,  there  might  be 
some  reason  for  considering  the  arguments  which  Hutchinson 
brings  forward  for  conservative  measures,  in  the  paper  which 
he  wrote  in  connection  with  his  own  case.  It  is  quite  possible  to 
conceive  that  with  an  organ  so  deeply  situated,  so  fixed,  and 
so  well  covered  by  the  close  apposition  of  other  parts,  healing 
might  take  place  and  a  good  result  accrue,  where  operative 
interference  would  prove  harmful.  It  is  quite  reasonable  to 
suppose  that  such  good  results  have  happened ;  it  is,  how- 
ever, quite  impossible  of  course  to  know.  The  only  question 
therefore  which  can  be  raised  is  regarding  the  proper  time 
to  operate.  To  attempt  any  grave  measure  when  the  patient 
is  in  a  collapsed  condition  is  likely  to  prove  as  useless 
as  to  operate  when  peritonitis  has  well  set  in.  The  proper 
time  therefore  is  after  the  primary  shock  has  passed  away  ; 
this  will  usually  be  in  the  course  of  a  few  hours. 

As  in  most,  if  not  all,  cases  the  diagnosis  will  be  purely  con- 
jectural; conjecture,  however,  will  give  place  almost  to  certainty 
if  the  surgeon,  on  opening  the  abdomen,  finds  by  the  presence 
of  gas  and  possibly  extravasated  material  the  evidence  of 
rupture,  yet  can  detect  no  lesion  in  any  part  of  the  stomach, 
jejunum,  ileum,  or  large  intestine.  A  careful  examination  of 
the  duodenum  will  then  probably  reveal  the  lesion. 

For  details  concerning  the  treatment  of  the  rupture,  the 
reader  must  refer  to  the  discussion  of  the  subject  in  connec- 
tion with  similar  lesions  of  the  jejunum  and  ileum ;  suffice  it 
to  say  here  briefly,  that  an  attempt  should  be  made  to  close 
the  severed  parts  by  suture.     Not  the  least  important  of  all 

T  2 


276  THE   DUODENUM 

treatment  is  the  efficient  washing  out  of  the  peritoneal  cavity, 
and  the  subsequent  drainage  of  the  part.  This  part  of  the 
treatment  itself  might,  in  the  case  of  a  small  lesion,  prove 
sufficient.  The  sole  after  danger  is  peritonitis,  and  the  sole 
prevention  is  early  operation,  thorough  cleansing  of  the 
peritoneal  cavity,  and,  if  necessary,  drainage. 

Case  IjVI. — Bupture  of  the  third  part  of  the  duodenum. 

A  soldier  aged  22  was  admitted  into  hospital  on  the  morning  of 
October  9,  having  been  kicked  in  the  abdomen  by  a  mule.  He  was 
knocked  down  by  the  blow,  and  being  unable  to  move  was  at  once  brought 
to  hospital  in  an  ambulance  waggon.  He  complained  of  severe  per- 
sistent pain  in  the  epigastrium,  and  lay  in  bed  with  his  knees  drawn  up. 
He  appeared  to  be  suffering  somewhat  from  shock,  but  his  pulse  was 
strong  and  regular,  and  respiration  normal.  On  examination  no  specially 
tender  spot  could  be  detected  ;  the  abdomen  presented  no  external  marks 
of  violence,  and  the  area  of  hepatic  dulness  did  not  appear  to  be  increased. 
He  vomited  slightly  after  the  administration  of  some  brandy,  but  again 
vomited  copiously,  bringing  np  the  contents  of  the  stomach  without  any 
admixture  of  blood.  After  this  he  appeared  relieved,  and  seemed  dis- 
posed to  sleep.  In  the  evening  he  seemed  doing  well,  and  passed  a  good 
night.  Unfavourable  symptoms,  however,  developed  the  following  morn- 
ing (the  lOtW  about  8.30  a.m.,  when  he  complained  of  intense  pain  in  the 
abdomen  and  suddenly  became  collapsed.  At  9.30  he  was  cyanosed  and 
j)ulseless.  Percussion  of  the  abdomen  revealed  absolute  dulness  all  down 
the  right  flank  and  extending  inwards  towards  the  middle  line.  Eespi- 
ration  was  very  laboured.  There  was  no  delirium.  Death  supervened  at 
10.45  A.M.,  nearly  twenty-four  hours  after  admission.  No  motion  was 
passed  while  he  was  in  hospital. 

Post  mortem. — There  was  no  bruising  of  the  abdominal  parietes. 
General  peritonitis  was  present.  The  only  lesion  found  was  an  opening 
an  inch  in  diameter  on  the  anterior  surface  of  the  lower  part  of  the 
duodenum,  the  margins  of  which  were  regular  and  deeply  congested. 
(Freeman,  '  Brit.  Med.  Journ.'  1889,  vol.  i.  p.  944.) 

Foreign  bodies.— The  lodgment  of  foreign  bodies  within 
the  duodenum  is  of  such  rare  occurrence  that  little  more 
than  a  passing  notice  is  necessary.  The  large  calibre  of  this 
portion  of  the  small  intestine  enables  most  foreign  bodies 
which  are  able  to  pass  the  jDylorus  to  find  their  way  lower 
down  before  becoming  impacted.  A  somewhat  extraordinary 
case  is  reported  by  Marshall.*  Complete  obstruction  took 
place  in  the  duodenum  owing  to  the  impaction  of  a  mass  of 
pins  weighing  about  a  pound. 

'   Trans.  Med.-Chir.  Soc.  Land.  1895,  vol.  xxxv.  p.  G5. 


ULCER  277 


CHAPTEK  XXXII 

DISEASE.       SIMPLE    OR    CHRONIC    ULCER.       ACUTE    ULCERATION 

'  In  110  part  of  the  alimentary  canal  are  the  diseases  to  which 
it  is  liable  so  obscure  in  their  origin  and  diagnosis  as  in  the 
duodenum.'  These  words,  written  more  than  fifty  years  ago 
by  Curling,  still  remain  applicable  at  the  present  day.  It  ia 
almost  as  difficult  now  as  it  appears  to  have  been  then  to 
distinguish  diseases  of  this  part  of  the  bowel  from  like 
affections  occurring  elsewhere  in  the  immediate  neighbour- 
hood. 

The  diseases  here  selected  for  treatment  are  only  such  as 
are  of  interest  to  the  surgeon. 

Simple  or  chronic  ulcer, — This  form  of  ulcer  resembles  in 
every  respect  the  simple  ulcer  of  the  stomach.  Not  only  in 
its  pathology,  but  in  the  symptoms  to  which  it  gives  rise  and 
ill  the  course  which  it  pursues,  it  shows  a  marked  resemblance 
to  that  ulcer.  Its  one  comparatively  minor  feature  of  dif- 
ference lies  in  the  fact  that  it  is  more  frequently  met  with 
in  males  than  in  females.  Out  of  sixty-four  cases  collected 
by  Krauss,^  only  six  were  females.  In  ten  cases  collected  by 
Kelynack  ^  from  the  '  Pathological  Eeports '  of  the  Manchester 
Eoyal  Infirmary,  all  were  males. 

The  commonest  age  for  the  appearance  of  the  ulcer  is 
between  30  and  40  years.  In  seven  out  of  ten  of  Kelynack's 
cases  the  average  age  was  about  33.  There  are,  however, 
marked  exceptions  at  both  periods  of  life.  Hebb  ^  records  the 
instance  of  a  man  aged  63  years,  and  a  female  child  aged 
3  months ;  and  Woods ''  reports  the  case  of  a  newly  born 
child.  Death  took  place  thirty-five  hours  after  birth  from 
perforative  peritonitis. 

With  but  few  exceptions  the  ulcer  is  found  within  one  or 
two  inches  from  the  pylorus  ;  and  it  more  frequently  occupies 

'  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  i.  D  — 6. 

^  Brit.  Med.  Journ.  1894,  vol.  ii.  p.  915. 

'  Westminster  Hosjntal  Reports,  1891,  vol.  vii.  p.  70, 

*  Medical  Press  and  Cimtlar,  1878,  vol.  i.  p.  88. 


278  THE   DUODENUM 

the  anterior  than  the  posterior  wall,  but  is  sometimes  found  at 
the  inferior  border. 

In  most  cases  it  is  usual  to  find  a  single  ulcer,  but  two  or 
more  are  sometimes  present,  and  now  and  again  an  ulcer  is 
found  in  addition  in  the  stomach.  In  two  out  of  three  cases 
reported  by  Mackenzie,'  two  ulcers  were  found  ;  and  in  a 
specimen  shown  by  Moore  ^  to  the  Pathological  Society  of 
London,  besides  the  ulcer  in  the  duodenum,  three  minute  ones 
were  found  in  the  stomach. 

Symptoms. — Although  extremely  variable,  the  symptoms 
may  sometimes  be  sufficiently  distinctive  to  warrant  a  posi- 
tive diagnosis  being  made.  Between  the  two  extremes  of  no 
symptoms  and  pronounced  symptoms  there  are  all  shades  of 
severity.  As  in  gastric  ulcer,  but  more  frequently  than  in 
that  condition,  the  patient  may  be  in  perfect  health  until 
suddenly  struck  down  with  symptoms  which  may  prove  fatal 
in  a  few  hours. 

In  an  exhaustive  paper  on  the  differential  diagnosis  between 
gastric  ulcer  and  duodenal  ulcer,  Bucquoy  ^  attaches  most 
importance  to  the  following  symptoms  as  distinctive  of  the 
latter  :  (1)  Copious  and  sudden  haemorrhage  by  the  bowel ; 
(2)  the  position  of  the  pain,  at  a  zone  corresponding  to  the 
inferior  border  of  the  liver  and  between  the  border  of  the  false 
ribs  and  the  iliac  crest ;  (3)  to  certain  digestive  troubles,  of 
which  the  most  important  are  acute  attacks  of  colic,  occurring 
three  or  four  hours  after  the  ingestion  of  food. 

That  duodenal  ulcer  may  be  present  and  yet  the  symptoms 
manifested  none  such  as  depicted  here,  is  sufficiently  attested 
by  numerous  published  cases.  As  regards  the  seat  of  pain, 
Koper  *  records  the  case  of  a  man  aged  55  who  complained 
of  pain  of  not  very  severe  character  in  the  epigastrium 
and  left  hypochondrium.  It  was  usually  worse  after  a  hard 
day's  work.  The  patient  described  the  pain  as  not  constant, 
both  as  regards  situation  and  period  of  appearance.  Some- 
times it  was  on  one  side,  sometimes  on  the  other,  and  fre- 
quently of  a  burning  character.     It  generally  started  at  the 

'  Lancet,  1888,  vol.  ii.  p.  1061. 

2  Trans.  Path.  Soc.  1883,  vol.  xxxiv.  p.  98. 

'  Archives  G&nirales  de  Midecine,  1887,  vol.  i.  pp.  398,  526,  691. 

*  Lancet,  1893,  vol.  i.  p.  1193. 


PLATE    XI. 


Fig.  41.— Perforating  Ulcer  of  Duodenum.— The  ulcer  is  situated  just  beyond  the 
pyloric  orifice.  The  floor  of  the  ulcer  is  formed  by  pancreatic  tissue.  The 
piece  of  whalebone  is  inserted  into  one  of  the  pancreatic  branches  of  the 
hepatic  artery,  which  has  been  opened  into  by  ulceration,  and  the  bleeding 
from  which  had  caused  death.     [R.I.M.,  Glas.) 


ULCER  279 

back,  and  then  travelled  to  the  side  or  the  epigastrium.  It 
never  appeared  to  have  any  relation  to  food  taken. 

The  severity  of  the  pain  and  its  period  of  appearance  are 
very  variable.  In  some  instances  it  is  very  acute,  doubling 
up  the  patient  while  it  lasts.  While  it  is  said  to  appear 
usually  from  two  to  four  hours  after  a  meal,  it  sometimes 
occurs  within  half  an  hour. 

Hfemorrhage,  when  present  to  any  extent,  is  almost  always 
manifested  by  a  copious  discharge  of  blood  j^er  rectum ;  in 
some  cases  it  is  accompanied  with  hsematemesis,  and,  when 
so  associated,  more  frequently  than  not  leads  to  a  mistaken 
diagnosis  of  gastric  ulcer.  In  a  case  published  by  Allchin,' 
the  patient,  a  man  aged  43,  had,  two  years  previous  to 
admission  to  hospital,  passed  a  considerable  quantity  of  blood 
per  rectum.  At  that  time  there  was  no  hsematemesis.  After 
no  particular  exertion  he  suddenly  vomited  an  enormous 
quantity  of  blood  and  fainted.  Death  occurred  in  thirty-six 
hours.  A  diagnosis  of  gastric  ulcer  was  made,  but  the  post 
mortem  revealed  a  duodenal  ulcer,  situated  about  one  inch 
from  the  pylorus.  In  a  somewhat  similar  case  reported  by 
Moore,^  melgena  was  associated  with  hsematemesis. 

In  estimating  the  relative  diagnostic  significance  of  haemor- 
rhage by  the  bowel  and  ha3morrhage  by  the  mouth,  bleeding 
from  a  gastric  ulcer  is  likely  to  be  more  abundant  by  the  latter 
than  per  rectum,  while  in  duodenal  ulcer  the  converse  will 
probably  be  the  case.  In  the  case  of  recurrent  small  haemor- 
rhages from  a  duodenal  ulcer,  the  blood  passed  per  rectum  will 
be  tarry  ;  while  in  similar  bleedings  from  the  stomach,  the  blood 
passed  will  be  more  altered  in  character  from  the  action  of  the 
gastric  juice. 

It  may  be  incidentally  pointed  out,  in  speaking  of  melaena, 
that  copious  haemorrhage,  even  to  the  extent  of  proving  fatal, 
may  take  place  from  the  bowel  as  the  result  of  causes  other  than 
ulceration  connected  either  with  the  stomach  or  the  duodenum. 
See  '  Malignant  Disease  of  the  Colon  and  Rectum.' 

Prognosis. — There  is  every  reason  to  believe  that,  like 
gastric  ulcers,  these  duodenal  ulcers  undergo  cicatrisation. 
The   obscurity   and   difficulty   which   attend   their   diagnosis 

'   Trans.  Path.  Soc.  Loncl.  1  87,  vol.  xxxviii.  p.  144. 
-     bid.  188.^1  vol.  xxxiv.  p.  98. 


280  THE  DUODENUM 

naturally  render  it  impossible  to  say  what  proportion  of  cases 
recover.  Bucquoy  claims  to  have  had  four  recoveries  out  of 
five  cases.  Planchard  ^  reports  a  case  where,  after  death  from 
perforation,  evidences  of  cicatrisation  were  seen  around  the 
ulcer,  showing  that  the  ulcer  was  an  old  one  and  had  under- 
gone considerable  repair. 

The  interest  of  these  cases  to  the  surgeon  centres  rather 
in  the  complications  which  arise  in  the  progress  of  the  disease 
than  in  the  simple  uncomplicated  disease  itself.  The  question 
of  the  excision  of  a  simple  duodenal  ulcer  has  not  yet  entered 
into  the  practical  domain  of  surgery,  as  it  has  done  in  the 
somewhat  analogous  case  of  gastric  ulcer.  Up  to  the  present 
the  surgeon  had  mostly  to  deal  with  the  results  of  ulceration, 
either  in  the  way  of  perforation,  or  in  its  later  after  effects, 
stricture. 

The  occurrence  of  haemorrhage  generally  lends  a  somewhat 
serious  aspect  to  a  case,  and  the  more  so  the  larger  the 
quantity  of  the  blood  lost  at  any  particular  time.  Not  a  few 
cases  are  recorded  (Coats  and  Gairdner,^  Allchin,^  Hebb,"^ 
Moore  ^)  where  death  has  suddenly  resulted  from  excessive 
haemorrhage.  In  this  particular  class  of  cases  the  ulcer  is 
always  situated  on  the  concave  aspect  of  the  bowel,  adherent 
to  the  pancreas  and  having  in  its  floor  a  perforation  involving 
the  gastro-duodenal  artery  or  one  of  its  branches. 

Perforation  of  the  ulcer  into  the  general  peritoneal  cavity 
is,  with  the  exception  of  severe  and  fatal  haemorrhage,  the  most 
serious  complication.  The  ulcer  in  these  cases  is  usually 
situated  on  the  anterior  part  of  the  first  portion  of  the  duo- 
denum, close  to  the  pylorus,  and  therefore  at  a  place  where 
communication  is  at  once  established  with  the  general  peri- 
toneal cavity.  As  a  rule  the  perforation  is  from  one  ulcer ; 
occasionally,  however — as  in  a  case  reported  by  Biggs  ^ — there 
are  two  ulcers,  both  of  which  have  perforations. 

This  complication  may  arise  as  the  first  symptom  of  the 
disease.     The  patient  may  be  enjoying  perfect  health  when  he 

'  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  i.  D — 13. 

2  Glasgoio  Med.  Journ.  1888,  N.S.  vol.  xxix.  p.  517. 

^  Trans.  Path.  Soc.  Land.  1887,  vol.  xxxviii.  p.  144. 

*  Westminster  Hospital  Reports,  1891,  vol.  vii.  p.  79. 

^  Trans.  Path.  Soc.  Lond.  188,8,  vol.  xxxiv.  p.  98. 

"  Ncvj  York  Med.  Joiirn.  18(0,  vol.  li.  p.  77. 


PLATE    XII. 


Fig.  42.— Perforating  Ulcer  of  Duodenum.— The  ulcer  is  situated  about  one  inch 
beyond  the  pylorus.  It  is  round  in  shape,  and  one -third  of  an  inch  in 
diameter.  The  base  is  formed  of  connective  tissue.  It  had  not  caused 
symptoms  during  life.     The  patient  died  of  heart  disease.     {W.I.M.,  Glas.) 


ULCER  281 

is  suddenly  struck  down  with  all  the  symptoms  of  acute  per- 
forative peritonitis.  As  in  the  case  of  gastric  ulcer,  perfora- 
tion maj''  take  place  at  any  time,  but  in  some  instances  it  is 
definitely  connected  with  distension  of  the  viscus.  In  two 
cases  published  respectively  by  Myers  ^  and  by  Murray,^  in 
one  it  occurred  after  a  heavy  bout  of  drinking,  and  in  the 
other  shortly  after  a  heavy  meal.  So  far  as  is  known,  every 
case  of  unoperated-upon  perforation  into  the  general  peritoneal 
cavity  has  proved  fatal  sooner  or  later.  Death  may  take 
place  in  a  few  hours  or  be  delayed  for  a  few  days. 

Barer  complications  are  such  as  result  from  the  cicatrisation 
of  the  ulcer.  A  case  is  reported  by  Svenson  and  Wallis  where 
the  inflammatory  thickening  around  the  ulcer  had  given  rise 
to  obliteration  of  the  common  bile  duct  and  cystic  duct.  The 
patient  died  of  exhaustion.  It  is  possible  also  for  the  hepatic 
and  pancreatic  ducts,  the  portal  vein  and  hepatic  artery  to  be 
obstructed.  Cicatrisation  of  ulcers  near  the  pylorus  will  give 
rise  to  symptoms  similar  to  those  due  to  obstruction  at  the 
pyloric  orifice.  A  still  rarer  complication  is  the  formation 
of  fistulse.  Bucquoy,  in  his  paper  already  quoted,  refers  to  a 
case  where  a  stercoraceous  fistula  formed  at  the  umbilicus. 
"West  ^  also  reports  a  case  of  abscess  which  formed  between  the 
ulcer  and  the  colon,  eventually  bursting  into  the  latter. 

Case  LVII. — Simple  ulcer  of  the  duodenum,  tvith  suhsequent  perforation. 
Tlie  patient  was  a  gentleman  aged  56,  who  for  two  or  three  years 
before  his  death  suffered,  at  first  occasionally  and  later  almost  daily,  from 
pain  to  the  right  of  the  epigastrium.  The  pain  always  came  on  about 
two  hours  after  a  meal.  Occasionally  there  were  exacerbations  of  the 
symptoms,  with  pyrosis.  Shortly  before  death  he  had  several  severe 
attacks  of  melsena,  with  occasional  vomiting,  the  vomit  containing  sar- 
cinag.  The  fatal  result  occurred  quite  suddenly  from  collapse,  within  an 
hour  or  two  after  the  perforation.  At  the  necropsy  a  large  ulcer  was  found 
situated  on  the  anterior  and  left  side  of  the  duodenum,  just  beyond  the 
pyloric  orifice.  He  was  seen  during  life  by  the  late  Dr.  Wilson  Fox,  who 
diagnosed  duodenal  ulcer.  In  fact,  durmg  the  later  stages  of  the  illness, 
the  nature  of  the  malady  was  manifest  from  the  recurrence  of  the  pain 
about  two  hours  after  each  meal,  its  situation  to  the  right  of  the  epigas- 
trium, and  the  melsena.     (Eve,  'Lancet,'  1894,  vol.  ii.  p.  1092.) 


Trans.  Path.  Sac.  Land.  1890,  vol.  xli.  p.  101.  -  Ibid. 

Brit.  Med.  Journ.  1893,  vol.  i.  p.  732. 


282  THE  DUODENUM 

Case  LVIII. — Shnple  ulcer  of  duodenutn  :  no  symj^toms  until 
loerforation. 
M.  C,  aged  27,  a  well-built  muscular  man,  was  brought  to  hospital  in 
an  almost  unconscious  condition.  He  had  been  engaged  at  his  usual 
work  and  apparently  in  perfect  health  till  12  noon  on  the  previous  day, 
when  he  was  seized  with  violent  abdominal  pain,  which  doubled  him  in 
two.  During  the  afternoon  he  vomited  some  reddish-coloured  fluid, 
which  was  thought  to  be  blood.  He  passed  rather  a  sleepless  night, 
suffering  considerable  pain,  but  was  able  the  following  morning  to  assist 
in  dressing  himself,  preparatory  to  removal  to  hospital.  On  admission 
he  was  cyanosed,  pupils  were  dilated,  sweating  on  forehead,  pulse  almost 
imperceptible,  abdomen  somewhat  distended  and  very  tympanitic.  Com- 
plete loss  of  liver  dulness.  It  soon  became  impossible  to  feel  the  pulse 
at  the  wrist,  and  within  fifteen  minutes  after  admission  respiration  had 
ceased.  At  the  post-mortem  examination  there  was  acute  general  peri- 
tonitis and  a  small  round  ulcer  situated  just  at  the  commencement  of  the 
duodenum  which  had  ruptured.  (Parsons,  '  Dublin  Journal  of  the  Medical 
Sciences,'  1892,  vol.  xciv.  p.  27.) 

Treatment. — Tn  cases  of  simple  uncomplicated  ulcer  the 
treatment  resolves  itself  into  one  of  careful  feeding.  The  diet 
is  limited  mostly  to  milk,  and  the  patient  is  kept  at  rest  in 
bed.  In  cases  of  haemorrhage,  ergotin  should  be  administered 
either  by  mouth  or  by  hypodermic  injection.  The  question 
of  transfusion  by  normal  saline  solution  should  be  entertained, 
and  the  remarks  upon  this  method  of  treatment  in  connection 
with  hsemorrhage  from  gastric  ulcer  will  be  equally  applicable 
here.     (See  page  180.) 

The  chief  interest  to  the  surgeon,  however,  attaches  itself 
to  the  treatment  of  those  cases  where  perforation  has  taken 
place.  It  is  only  within  comparatively  recent  years  that 
operative  interference  has  been  considered.  The  success  which 
has  attended  the  surgical  treatment  of  perforation  in  cases  of 
gastric  ulcer  is,  from  the  perfect  similarity  of  the  two  diseases, 
a  sufficient  encouragement  to  hope  for  like  good  results  in 
this  condition  ;  and,  if  further  encouragement  were  required, 
the  case  brought  before  the  Medical  Society  of  London  in 
May  1894  by  Dean  ^  is  sufficient  of  itself  to  establish  the 
practice  of  laparotomy  as  the  proper  procedure  in  all  these 
cases.  In  the  case  here  referred  to,  the  operator  succeeded 
in  excising  the  ulcer  and  curing  the  patient.  While  up  to 
the    present  this  appears  to  be  the  only  success  which  has 

'  Brit.  Med.  Joimi.  1894,  vol.  i.  p.  1014. 


PLATE    XIII. 


Fig.  43. — Perforating  Ulcer  of  Duodenum.— Equal  portions  of  the  stomach  and 
duodenum  are  shown,  the  pyloric  ring  being  indicated  by  a  transverse  ridge. 
A  piece  of  the  left  lobe  of  the  liver  is  seen  behind,  into  which  the  ulcer 
penetrated.     (W.I.M.,  Glas.) 


ULCER  283 

been  obtained,  attempts  have  been  made  in  two  cases  by 
Lockwood '  and  in  one  by  Eve ;  ^  and  although  unsuccessful 
they  have  not  been  without  value  in  throwing  some  light 
which  may  prove  of  future  service. 

Tt  is  needless  to  give  here  in  detail  a  line  of  treatment 
which  in  all  respects  resembles  that  already  fully  described 
in  cases  of  perforation  of  gastric  ulcer.  The  two  main  points 
to  which  the  surgeon  must  direct  his  attention  are  the  ulcer 
and  the  peritoneal  extravasation.  The  ideal  treatment  of  the 
former  will  be  its  removal  and  the  closure  of  the  orifice.  Such 
was  the  treatment  successfully  carried  out  by  Deaii :  *  The 
portion  removed  was  elliptical  in  shape,  measuring  an  inch 
and  a  quarter  in  its  long  axis,  which  was  parallel  with  the 
transverse  axis  of  the  gut.  The  portion  excised  was  found  to 
include  the  ulcer  and  a  margin  of  healthy  mucous  membrane. 
In  the  centre  of  the  ulcer  was  a  perforation  about  2  mm.  in 
diameter  .  .  .  the  elliptical  opening  thus  made  in  the  duo- 
denum was  sewn  up  by  silk  sutures  according  to  Lembert's 
method.'  Cases,  however,  will  occur  where  no  such  complete 
removal  is  possible.  The  surgeon  will  then  have  to  consider 
whether  it  is  advisable — if  possible — to  close  the  orifice  by  the 
passage  of  a  series  of  Lembert  sutures  outside  the  area  of  the 
ulcer,  approximating  the  serous  surfaces  and  at  the  same  time 
folding  in  the  ulcer,  as  under  similar  circumstances  of  gastric 
ulcer ;  or  whether  he  must  be  satisfied  with  proper  washing  out 
of  the  part,  drainage,  and  stuffing  the  region  with  iodoform 
gauze  to  prevent  further  general  extravasation. 

With  regard  to  the  peritoneal  cavity,  it  should  be  freely 
washed  out  with  hot  water,  or,  if  preferred,  with  a  warm  weak 
solution  of  some  antiseptic.  Whether  a  drainage  tube  should 
be  used  and  the  abdominal  incision  not  completely  closed  will 
depend  much  upon  the  efficiency  with  which  ablution  can  be 
carried  out.  If  there  is  any  doubt  as  to  this  a  drainage  tube 
should  be  inserted  and  made  to  pass,  as  may  seem  advisable, 
either  down  to  the  seat  of  the  disease,  or  into  the  cavity  of  the 
pelvis  where  extravasated  material  usually  gravitates. 

It  may  be  remarked  here  with  regard  to  the  incision 
through    the   parietes,    that   if  the   operation   is   performed 

'   Trans.  Med.  Soc.  Land.  1892,  vol.  xv.  p.  91. 
-  Lancet,  1894,  vol.  ii.  p.  1091. 


284  THE   DUODENUM 

deliberately  to  deal  with  the  duodenum,  the  incision  should  be 
in  the  median  line  above  the  umbilicus.  Where,  however,  as 
most  frequently  happens,  the  operation  is  performed  for  a 
possible  perforative  peritonitis  the  cause  of  which  is  not 
known,  the  incision  is  made  below  the  umbilicus,  and  must  be 
extended  upwards  to  afford  efficient  inspection  and  treatment 
of  the  duodenum.  For  proper  drainage  of  the  pelvic  cavity, 
where  this  is  deemed  necessary,  the  tube  must  be  brought  out 
through  an  incision  below  the  umbilicus. 

The  treatment  of  stricture  as  the  result  of  a  healed  ulcer 
will  be  dealt  with  when  discussing  the  subject  of  stricture 
itself. 

The  after  treatment  of  cases  of  operation  for  perforative 
peritonitis  will  in  all  respects  resemble  that  to  be  adopted  in 
the  analogous  instance  of  perforation  of  a  gastric  ulcer.  (See 
page  190.) 

Acute  ulceration. — In  contradistinction  to  the  slowly  formed 
ulcer  just  described,  there  is  a  class  of  cases  where  the  process 
is  a  comparatively  rapid  one.  The  patients  in  whom  this 
form  of  ulceration  is  found  have  usually  been  the  subjects 
of  severe  burns,  involving  as  a  rule  a  considerable  part  of 
the  surface  of  the  body.  Occasionally,  though  rarely,  it  has 
happened  in  other  affections,  as,  for  instance,  in  septicaemia. 
Ever  since  Curling's  memorable  paper,^  read  before  the 
Medico-Chirurgical  Society  of  London  in  1842,  a  lingering 
interest  has  always  attached  to  the  subject.  Modern  experience 
contrasts  strangely  with  what  seems  to  have  occurred  in 
Curling's  time.  This  surgeon  was  able  to  collect  no  fewer 
than  ten  cases,  which  came  under  his  observation  within  a 
comparatively  few  years  ;  while  at  the  present  day  there  are  not 
a  few  surgeons  of  large  experience  in  hospital  practice  who  have 
never  met  with  a  single  instance.  However,  cases  do  crop 
up  occasionally,  sufficient  to  make  it  certain  that  there  does 
appear  something  of  the  nature  of  true  cause  and  effect. 

Various  theories  have  been  promulgated  as  to  the  reason 
of  this  ulceration.  Curling's  original  suggestion  was  that  the 
extensive  destruction  of  the  skin  led  to  an  extra  activity  of 
Briinner's  glands.  The  sweat  glands  of  the  skin  being  de- 
stroyed over  a  large  area,  an  increased  activity  takes  place  in 

'   Society's  Trcms.  1842,  vol.  xxv.  p,  2(10 


ACUTE   ULCERATION  285 

the  analogous  Briinner's  glands,  and  these  latter  being  situated 
in  that  part  of  the  duodenum  which  is  most  prone  to  inflam- 
mation, that  is  the  first  part,  ulceration  rapidly  ensues. 

The  most  recent  contribution  to  the  pathology  of  the 
condition  is  by  Hunter,^  who  attributes  the  ulceration  to  the 
absorption  of  septic  poisons  which,  being  excreted  by  the  bile, 
have  an  irritative  effect  upon  the  mucous  membrane,  and  so 
give  rise  to  acute  congestion  and  ulceration.  He  bases  his 
theory  upon  experiments  performed  upon  dogs.  Toluylene- 
diamin  was  injected  into  the  circulation  of  dogs,  and  after 
being  killed,  ulcers  were  found  in  the  duodenum  resembling 
those  found  after  burns. 

The  occurrence  of  these  ulcers  in  the  same  part  of  the 
bowel  as  those  of  the  more  simple  or  chronic  type  seems  to 
suggest  a  similar  cause,  only  one  acting  more  acutely.  The 
theory  that  the  formation  of  the  chronic  ulcer  is  due  to  non- 
neutralised  action  of  the  acid  gastric  juice  upon  a  limited 
area  of  the  bowel,  deprived  of  its  normal  blood  supply  by 
embolism  or  thrombosis  in  some  small  artery,  would  equally 
apply  in  the  case  of  the  acute  ulcer.  In  this  instance  it  is 
assumed  that  the  same  deprivation  of  blood  supply  takes 
place,  owing  to  the  absorption  of  septic  material  which  readily 
conduces  to  the  production  of  capillary  embolism  or  thrombosis. 
The  fact  that  ulceration  appears  to  manifest  itself  usually  at 
that  stage  when  sloughs  are  separating  and  suppuration  is 
most  abundant  would  seem  to  give  some  support  to  the 
theory.  For  it  is  at  this  particular  time  that  the  blood, 
surcharged  with  effete  material  absorbed  from  the  surface  of 
the  body,  is  most  likely  to  clot  and  become  the  source  of 
thrombosis  or  embolism.  Such  a  theory  would  also  well 
account  for  the  rarity  with  which  the  complication  is  now 
met.  For  the  modern  antiseptic  treatment  of  burns  lessens 
largely  the  very  condition  which  in  earlier  years  proved  such 
a  serious  stage  in  the  later  course  of  a  severe  burn. 

There  are  no  very  marked  characteristics  of  these  ulcers. 
Situated  as  a  rule  close  to  the  pylorus,  they  are  usually 
single,  although  in  some  instances  two,  three,  or  more  are  met 
with.  The  mucous  membrane  of  the  bowel  may  be  congested 
and  inflamed,  although  the  immediate    surrounding   of   the 

'   Trans.  Patli.  Soc.  Loncl.  1890,  vol.  xli.  p.  105. 


286  THE   DUODENUM 

ulcer  is  sometimes  free  from  inflammation.  Their  shape  and 
size  vary,  sometimes  round  or  oval,  at  other  times  quite  irregular 
in  outline.  The  margins  of  the  ulcer  are  frequently  sharply 
cut  and  undermined.  They  may  cicatrise  completely,  or  pro- 
gress till  perforation  takes  place,  and  then  communicate  either 
with  an  artery  or  with  the  general  peritoneal  cavity.  In 
illustration  of  their  cicatrising,  a  case  may  be  cited,  reported  by 
Holmes,^  of  a  child  who  had  been  severely  burnt  and  died  on 
the  twenty-eighth  day,  apparently  from  an  attack  of  pneumonia. 
At  the  post  mortem  a  circular  patch  about  the  size  of  a  four- 
penny  piece  was  found  at  the  commencement  of  the  duodenum, 
where  the  mucous  membrane  was  deficient  and  the  exposed 
surface  cicatrised.  From  this  case,  together  with  another 
similar  one  given  by  Curling,  as  also  the  fact  of  the  frequent 
non-existence  of  symptoms  in  cases  which  may  end  fatally  by 
perforation,  Holmes  considers  it  not  improbable  that  ulcer 
may  be  a  much  commoner  incident  of  burns  than  at  present 
supposed,  its  existence  being  an  unrecognised  complication  in 
many  cases  which  recover. 

The  lesion,  if  it  is  to  lead  to  a  fatal  result,  usually  does  so, 
according  to  Curling,  some  time  between  the  seventh  and  the 
seventeenth  day.  There  are,  however,  many  examples  of  this 
period  being  both  shorter  and  longer.  Out  of  sixteen  fatal 
cases  collected  by  Holmes,  five  died  during  the  first  week,  five 
during  the  second,  and  the  remaining  six  after  longer  periods. 
The  shortest  period  was  four  da^'s,  while  the  longest  was 
seventy-five. 

Children  appear  to  afford  the  majority  of  fatal  cases ;  the 
instances,  however,  of  death  occurring  late  in  life  are  not  a  few. 
As  examples  of  the  extremes  of  ages,  one  of  Curling's  cases 
was  a  child  aged  3  years,  and  one  of  Holmes's  a  man  aged  78 
years. 

There  appears  to  be  no  definite  relation  between  the  region 
of  the  body  burnt  and  the  appearance  of  ulceration.  Although 
in  the  majority  of  instances  either  the  abdomen  or  the  chest 
has  been  involved,  in  one  case  reported  by  Southam,^  only 
the  face,  arms,  and  thighs  were  implicated.  In  two  of 
Holmes's  cases  the  extremities  only  had  been  burnt  and  in  a 

'  System  of  Surgery,  3rd  edit.  vol.  i.  p.  395. 
2  Lancet,  1890,  vol.  i.  p.  168. 


ACUTE    ULCERATION  287 

case  related  by  Morton  '  the  lower  extremities  andtlie  mucous 
membrane  of  the  rectum  alone  had  suffered. 

Symptoms. — In  nearly  all  the  recorded  cases  there  have 
been  no  symptoms  to  indicate  the  lesion  in  the  bowel,  until 
the  occurrence  of  a  severe  haemorrhage  or  of  a  fatal  perfora- 
tion. It  is  possible,  as  Curling  suggests,  that  any  symptoms 
which  might  otherwise  manifest  themselves  are  masked  by  or 
attributed  to  the  more  gross  lesion  on  the  surface  of  the  body, 
or  other  general  disturbances.  A  ? ense  of  discomfort  amount- 
ing to  pain  might  be  expected  to  show  itself  in  or  to  the  right 
of  the  epigastric  region,  with  some  tenderness  on  palpation  of 
the  part.  There  may  be  some  derangement  in  gastric  digestion. 
Diarrhoea  and  vomiting  may  be  present,  although  these  may 
owe  their  appearance  to  other  causes.  The  presence  of  blood 
in  the  vomit  or  stools  will  necessarily  suggest  the  probable 
existence  of  ulceration ;  while  the  si  dden  onset  of  acute 
abdominal  pain,  with  other  symptoms  of  collapse,  will  leave 
little  doubt  that  an  ulcer  has  perforated  into  the  abdominal 
cavity. 

Treatment. — It  is  hardly  possible  to  speak  of  the  treatment 
of  a  disease  the  very  presence  of  which  it  is  frequently  so  diffi- 
cult, if  not  impossible,  to  determine.  When,  however,  there  is 
reason  to  suspect  the  existence  of  ulceration,  the  diet  should 
for  some  time  be  limited  to  milk  and  other  mild  fluid  nourish- 
ment. Eest  will  hardly  need  to  be  enforced,  for  the  patient 
will  probably  be  incapacitated  from  exercising  any  movement, 
by  reason  of  the  surface  condition  of  the  body.  Where  possible. 
Curling  suggests  the  application  of  leeches  over  the  duodenum  ; 
and  to  allay  pain,  the  administration  at  intervals  of  a  few 
grains  of  grey  powder  combined  with  opium.  The  appearance 
of  hsemorrhage  will  need  to  be  combated  by  the  usual  hasmo- 
statics :  the  administration  of  ergotin  by  the  mouth  or  by  sub- 
cutaneous injection. 

When  symptoms  of  perforation  manifest  themselves,  the 
usual  means  now  adopted  for  this  complication  arising  from 
other  conditions  should  be  practised.  The  treatment  does  not 
appear  to  have  been  tried  ;  but  as  the  natural  course  of  the 
complication  is  inevitably  a  fatal  one  :  to  open  the  abdomen, 
search  for  the  perforation,  and  treat  it  and  the  general  peritonitis 

'  International  Encyclopczdia  of  Stirgery,  vol.  ii.  p.  240. 


288  THE   DUODENUM 

can  add  no  additional  danger,  but  on  the  contrary  may  hold 
out  some  hope  of  a  cure.  It  is  fairly  reasonable  to  believe 
therefore  that,  where  the  operation  is  performed  promptly  and 
carried  out  efficiently,  there  is  as  much  likelihood  of  a  good 
result  accruing  as  in  the  case  of  perforation  from  the  simple 
or  chronic  form  of  ulcer. 

Case  LIX. —  Ulceration  of  the  duodenum  after  a  burn. 
The  patient,  a  man  aged  38  years,  M'as  admitted  into  hospital  in 
October  1889.  He  had  extensive  burns  about  the  face,  arms,  and  thighs, 
whicli  proved  fatal  on  the  twelfth  day.  For  the  first  eleven  days  the 
highest  temperature  recorded  was  103"2°.  During  the  last  twenty- 
four  hours  the  temperature  rose  steadily  and  rapidly,  until  shortly  before 
death  the  thermometer  registered  110'2°.  During  the  last  few  days  he 
complained  of  pain  and  tenderness  on  pressure  in  the  epigastiic  region. 
Otherwise  there  were  no  special  features  in  connection  with  the  case,  nor 
were  there  any  other  symptoms  indicative  of  the  presence  of  duodenitis. 
At  the  necropsy  the  duodenum,  especially  at  its  commencemont,  was  found 
deeply  congested.  Close  to  the  pylorus  were  found  two  well-defined 
ulcers,  u-regular  in  shape,  with  slightly  raised  edges,  the  largest  measuring 
an  inch  and  a  half  by  three-quarters  of  an  inch.  Their  bases  were  formed 
by  the  muscular  coat,  the  ulceration  not  extending  deeper  than  the  sub- 
mucous tissue.  With  the  exception  that  there  was  marked  congestion  of 
both  lungs,  the  other  viscera  were  healthy,  (Southam,  '  Lancet,'  1890, 
vol.  i.  p.  168.) 

CHAPTEE   XXXIII 

TUMOURS  :    INNOCENT  AND   MALIGNANT.       STETCTURE.       CONGENITAL 
STENOSIS    AND   OBLITERATION.      PERFORATION    FROM    EXTERNAL 

CAUSES 

Tumours. — Of  the  two  great  classes  of  tumours,  innocent 
and  malignant,  the  former  is  the  one  more  commonly  met  with. 
Both,  however,  are  extremely  rare. 

Innocent  growths. — Tumours  other  than  those  of  a  malig- 
nant character  are  extremely  rare.  They  may,  however,  prove 
equally  as  fatal  in  the  obstruction  which  they  caase.  A  case 
of  fibro-myxoma  of  the  duodenum  is  reported  by  Foxwell.^ 
A  woman  aged  28  years  suffered  from  symptoms  akin  to  those 
of  pyloric  stenosis.  After  death  a  tumour  about  three  times 
the  size  of  a  chestnut  was  found  at  the  junction  of  the  second 
and  third  parts. 

'  Lancet,  1889,  vol.  i.  p.  1239. 


MALIGNANT   TUMOURS  289 

Malignant  tumours. — Primary  malignant  disease  of  the 
duodenum  is,  according  to  some  statistics  collected  by  Wliittier,^ 
only  met  with  in  one  per  cent,  of  all  the  cases  where  some  part 
of  the  small  intestine  is  involved.  It  may  exist  in  the  form 
of  carcinoma  or  sarcoma.  In  the  former  case  the  disease 
originates  most  frequently  about  the  orifice  of  the  bile  duct. 
As  it  progresses  ulceration  takes  place,  and  obstruction  may  be 
caused  either  in  the  bowel  or  in  the  bile  duct. 

The  form  of  carcinoma  is  most  frequently  of  the  cylinder- 
celled  variety.  In  two  specimens  depicted  by  Kast  and 
Eumpel,^  the  growth  was  examined  microscopically  and  found 
to  be  a  cylinder-celled  epithelioma.  In  the  thirteen  cases  of 
malignant  disease  collected  by  Whittier,  there  is  no  mention 
of  any  microscopical  examination  having  been  made.  The 
various  types  of  disease  present  are  spoken  of  as  scirrhus, 
encephaloid,  spongy,  or  fungous. 

When  sarcoma  attacks  the  duodenum,  it  as  a  rule  ti'avels 
round  the  bowel,  so  forming  a  mass  which  to  some  extent 
maintains  the  shape  of  the  part,  but  through  encroachment 
upon  the  interior  soon  lessens  its  calibre.  The  cells  of  which 
the  growth  is  composed  are  usually  small  and  round,  and,  from 
the  occasional  admixture  of  some  few  delicate  fibrils,  assume 
the  character  of  a  lympho-sarcoma.  In  some  instances  it 
appears  as  if  the  tumour  arose  in  the  submucous  tissue,  while 
in  others  its  origin  seems  more  likely  to  be  from  the  neigh- 
bouring lymphatic  glands.  A  case  recorded  by  Rolleston  ^ 
would  illustrate  the  former,  while  one  reported  by  Moore* 
would  seem  to  suggest  the  latter  ;  in  this  latter  instance  the 
mesenteric  and  lumbar  glands  were  greatly  enlarged. 

Tumours  having  their  origin  elsewhere,  and  only  second- 
arily involving  the  duodenum,  must  be  distinguished  from 
primary  affections  of  the  part.  Clinically,  however,  such 
distinction  may  not  be  possible,  the  secondary  implication  of 
the  bowel  being  the  primary  cause  of  the  most  prominent 
symptoms.  Tumour  therefore  arising  in  connection  with  the 
head  of  the  pancreas  will  soon  seriously  implicate  the  bowel. 

'   Trans,  of  the  Association  of  American  Physicians,  1889,  vol.  iv.  p.  292. 
-  Illustrations  of  Pathological  Anatomy,  Part  3,  English  edit. 
3  Trans.  Path.  Soc.  Loncl.  1892,  vol.  xliii.  p.  67. 
*  Ibid.  1883,  vol.  xxxiv.  p.  99. 


290  THE   DUODENUM 

In  a  case  reported  by  Cahn/  a  mass  of  retroperitoneal  glands 
had  so  pressed  upon  the  lower  part  of  the  duodenum  as  to 
cause  obstruction,  A  remarkable  symptom  was  the  large 
quantity  of  bile  which  was  removed  from  the  stomach  after  the 
first  few  washings  had  been  carried  out. 

Symptoms. — It  is  not  possible  as  a  rule  to  indicate  any  sym- 
ptoms which  specifically  indicate  that  they  owe  their  origin  to 
primary  disease  of  the  duodenum.  The  various  symptoms  which 
do  show  themselves  are  frequently  as  attributable  to  disease 
connected  with  the  stomach,  jejunum,  or  neighbouring  parts. 

The  inevitable  result  of  a  growth,  either  carcinomatous  or 
sarcomatous,  is  to  produce  a  gradual  diminution  in  the  calibre 
of  the  bowel.  Symptoms  of  obstruction,  however,  may  not 
show  themselves  until  a  comparatively  late  stage  of  the  disease, 
the  reason  of  this  being  that  the  material  which  passes  through 
the  strictured  portion  is  naturally  of  a  somewhat  fluid  con- 
sistency. As  soon,  however,  as  obstructive  influences  come 
into  play,  various  symptoms  arise.  Dilatation  of  the  stomach 
follows,  and  this  may  be  accompanied  by  a  corresponding 
dilatation  of  the  part  of  the  duodenum  above  the  obstruction. 
In  one  of  Whittier's  collected  cases  this  dilatation  had  taken 
place  to  such  an  extent  that  there  was  no  essential  difference 
in  size  between  the  stomach  and  the  first  six  or  eight  inches 
of  the  duodenum.  A  further  result  of  increasing  obstruc- 
tion will  be  various  gastric  disturbances  with  vomiting.  The 
gradually  diminishing  passage  of  material  through  the  ob- 
structed part  will  soon  give  rise  to  emaciation,  and  the  patient 
will  suffer  from  flatulence  and  colicky  pains.  External  manipu- 
lation may  indicate  the  presence  of  a  tumour  in  the  epigastric 
or  right  hypochondriac  region. 

In  diseases  which  attack  the  region  of  the  biliary  orifice — 
that  is,  the  second  or  descending  part  of  the  duodenum — 
obstruction  to  the  outflow  of  bile  may  take  place,  with  the 
result  that  jaundice,  distension  of  the  gall  bladder,  and  other 
symptoms  dependent  thereon  will  become  manifest.  Ulceration 
may  cause  haemorrhage,  which  will  show  itself  either  in  the 
vomit  or  in  the  stools.  Should  the  ulceration  open  up  one  of 
the  pancreatico- duodenal  arteries,  a  fatal  result  would  ensue. 
Other  causes  of  death  are  perforation  and  general  peritonitis, 
'  Berliner  klin.  Wochcnschrift,  188G,  No.  22,  p.  353. 


.^[ALIGNAXT   TUMOUlfS  291 

acute  intestinal  obstruction,  and  gradual  exhaustion,  the  last 
being  the  most  frequent  cause. 

Treatment. — As  purely  palliative  measures,  much  relief  will 
be  obtained  by  the  use  of  suitable  diet,  and  by  periodically 
washing  out  the  stomach.  Kadical  measures  can  be  less  en- 
tertained than  in  other  portions  of  the  gastro-intestinal  canal ; 
only  in  the  most  exceptional  instances  of  disease  located  near 
the  pylorus  is  it  possible  to  consider  the  question  of  extirpa- 
tion. The  deep  situation  and,  above  all,  the  intimate  connec- 
tions of  the  second  and  third  parts  of  the  duodenum  with  the 
pancreas,  the  blood  vessels,  and  the  hepatic  ducts,  render  any 
such  operation  impracticable.  It  is,  however,  not  unreasonable 
to  consider  that  temporary  relief  might  be  afforded  by  the  per- 
formance of  gastro-enterostomy.  The  diversion  of  the  food 
from  the  stomach  to  the  jejunum  should  afford  equal,  if  not 
greater,  relief  than  in  the  case  of  pyloric  stenosis  for  which  the 
operation  is  usually  performed. 

Stricture. — Independently  of  the  narrowing  of  the  canal 
from  disease  within  or  from  the  pressure  of  tumours  without, 
there  are  some  cases  where  true  cicatricial  stenosis  occurs. 
The  comparatively  large  diameter  of  the  canal,  the  fluid  nature 
of  the  material  which  passes  through  it,  together  with  the 
improbability  that  chronic  ulceration  ever  extends  sufficiently 
far  even  to  produce  serious  narrowing,  all  tend  to  render  ob- 
struction from  this  cause  of  infrequent  occurrence.  In  all 
cases  cicatricial  stenosis  owes  its  origin  to  previous  ulceration  ; 
and  this  again  is  either  the  result  of  gall  stones  or  of  those 
causes,  whatever  they  may  be,  which  give  rise  to  the  simple  or 
chronic  ulcer. 

Symptoms. — The  symptoms  in  the  main  are  those  of 
obstruction,  but  their  character  differs  according  to  whether 
the  stricture  is  above  or  below  the  orifice  of  the  bile  duct. 
Where  the  stricture  is  close  to  the  pylorus,  it  is  not  possible  to 
differentiate  between  this  condition  and  that  of  pyloric  stenosis. 
As  the  seat  of  obstruction,  however,  recedes  from  the  pylorus, 
the  character  of  the  symptoms  changes  somewhat.  Thus  it  has 
been  found  that  after  the  stomach  has  been  washed  out  and 
emptied,  the  patient  would  again  vomit  large  quantities  of 
material  some  few  hours  afterwards.  The  reason  of  this 
appears  to  be  that  a  quantity  of  material  lodges  in  the  duodenum 


292  THE    DUODENUM 

at  the  time  of  washing  out  the  stomach,  but  later  it  is  returned 
and  ejected.  Some  importance  may  also  be  attached  to  the 
variability  which  exists  in  the  digestive  powers  of  the  gastric 
juice  and  in  the  proportion  of  free  hydrochloric  acid  present. 
At  one  time  the  gastric  secretion  may  contain  free  hydrochloric 
acid  and  possess  active  digestive  properties,  while  at  another 
the  reverse  will  be  the  case.  The  explanation  of  this  appears 
to  be  in  the  occasional  regurgitation  of  the  alkaline  juice  of 
the  duodenum  into  the  stomach,  and  so  a  neutralising  of  the 
acid  and  an  interference  with  the  normal  digestive  properties 
of  the  secretion.  Boas  ^  reports  a  case  of  constriction  from 
chronic  ulcer.  The  stomach  pump  when  used  on  one  occasion 
removed  about  a  quart  of  dark,  bilious,  odourless  chyme,  the 
microscopical  examination  of  which  showed  neither  torulse 
nor  sarcinae.  The  reaction  was  slightly  acid,  but  no  free  hydro- 
chloric acid  was  detected.  Much  peptone  and  egg-albumen 
were  present,  and  fibrin  was  easily  digested  by  it.  In  stricture 
situated  below  the  orifice  of  the  bile  duct  there  will  be  a 
regurgitation  of  bile  into  the  stomach,  with  interference  with 
digestion,  and  the  presence  of  bile  in  the  vomit. 

Hochhaus,^  who  in  his  report  of  three  cases  has  devoted 
considerable  attention  to  the  subject  of  duodenal  stenosis, 
attaches  some  importance  to  the  existence  of  a  previous 
history  of  gall  stones.  In  each  of  his  three  cases  the  ulcera- 
tion was  due  to  gall  stones.  In  his  first  case  the  stenosis 
was  close  to  the  pylorus,  in  the  second  it  was  at  the  junction 
of  the  duodenum  and  the  jejunum,  and  in  the  third  it  in- 
volved both  the  duodenum  and  the  pylorus. 

Lange^  reports  an  interesting  case  of  stenosis  from  the 
cicatrisation  of  a  chronic  ulcer  situated  close  to  the  pylorus. 
The  patient,  a  woman,  had  for  long  suffered  from  symptoms 
which  suggested  ulcer  of  the  stomach,  for  which  she  was 
treated.  Later  her  condition  was  such  as  to  indicate  stricture 
about  the  pylorus.  Additional  interest  attaches  to  this  case 
from  the  fact  that  the  stricture  was  successfully  dealt  with  by 
the  performance  of  pyloroplasty  (Heineke-Mikulicz)  or,  as  it 
should  be  more  i^roperly  termed,  duodenoplasty. 

'  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  i.  D — 11. 
-  Berliner  klin.  Woclienschrift,  1891,  No.  17,  p.  409. 
^  Annals  of  Stirgery,  1893,  vpl.  xvii.  p.  588. 


CONGENITAL   STENOSIS   AND  OBLITERATION  293 

Treatment. — It  is  hardly  possible  to  do  more  than  suggest 
a  line  of  treatment  in  a  class  of  cases  so  rarely  met  with  and 
still  more  rarely  treated.  Bat  the  success  which  attended 
Lange's  case  sufficiently  indicates  the  proper  course  to  follow 
in  all  similar  instances.  Where  an  exploratory  laparotomy 
reveals  constriction  of  the  bowel  lower  down,  it  is  possible 
that  a  like  plastic  operation  might  be  performed.  When  it  is 
remembered  that  life  can  only  be  retained  by  securing  a 
proper  flow  of  the  bile  and  pancreatic  secretion  downwards 
into  the  lower  bowel,  something  may  reasonably  be  attempted 
to  bring  this  end  about. 

Congenital  stenosis  and  obliteration. — Cases  now  and  then 
crop  up  where  a  child  lives  for  three  or  four  days  after  birth 
and  then  dies  with  symptoms  of  obstruction.  At  the  post 
mortem,  failing  the  evidence  of  a  stoppage  elsewhere,  either 
stricture  or  a  complete  obliteration  is  found  in  some  part  of 
the  duodenum.  Judging  from  the  very  few  cases  recorded,  the 
condition  must  be  a  rare  one,  and  when  it  is  met  with,  the 
symptoms  are  not  such  as  to  point  to  the  duodenum  as 
the  part  where  the  obstruction  is  seated. 

The  child  at  birth  may  present  all  the  appearances  of 
good  health,  but  on  the  second  or  third  day  it  begins  to  refuse 
the  breast  and  vomits,  bringing  up  at  first,  it  may  be,  a  little 
mucus  with  the  contents  of  the  stomach,  but  later  this  is 
mingled  with  bile  if  the  obstruction  be  below  the  orifice  of 
entrance  of  the  duct.  In  one  case  it  had  the  appearance  of 
meconium,  and  in  two  some  blood  was  present.  Meconium 
may  pass  per  rectum. 

The  situation  of  the  constriction  or  obliteration  appears 
more  frequently  in  the  upper  part  of  the  bowel.  In  a  case 
recorded  by  Anderson,^  about  one  inch  of  the  duodenum  close 
to  the  pylorus  was  absent,  each  end  above  and  below  the 
deficiency  formed  a  perfect  cul-de-sac.  In  another  case,  by 
Hobson,^  the  duodenum  ended  about  one  inch  beyond  the 
pylorus  in  a  blind  pouch,  and  on  tracing  the  bowel  upwards 
it  was  also  found  to  end  in  a  cul-de-sac,  at  the  top  of  the 
head  of  the  pancreas.  In  a  third  case,  reported  by  Emerson,^ 
a  tight  constriction  almost,  but  not  quite,  occluded  the  bowel 

'  New  York  Medical  Record,  1889,  vol.  xxxv.  p.  329. 

-  Brit.  Med.  Journ.  1893,  vol.  i.  p.  637. 

^  New  Yoi-k  Med  Journ.  1890,  vol.  lii.  p.  153. 


294  THE   DUODENUM 

just  above  the  orifice  of  the  bile  duct.  In  a  fourth  case,  by 
Porak  and  Bernheim,'  the  stomach  communicated  by  a  con- 
tracted pylorus  with  a  blind  pouch  which  terminated  near  the 
pancreas. 

The  primary  cause  of  these  conditions  can  only  be  con- 
jectural, but  it  is  probable  that  those  cases  in  which  a  certain 
part  of  the  bowel  appears  absent,  and  the  ends  terminate  in 
cul-de-sacs,  owe  their  origin  to  some  defect  in  development ; 
while  those  in  which  there  is  stenosis,  it  is  probable  that  the 
constriction  owes  its  origin  to  the  cicatrisation  of  a  simple 
or  chronic  ulcer,  since  such  ulceration — as  has  been  already 
pointed  out — is  occasionally  found  in  the  new-born  child. 

Diagnosis, — The  cafes  have  been  too  few  to  form  a  basis 
for  any  diagnostic  purposes.  Only  an  approximate  diagnosis 
can  be  arrived  at,  and  that  mostly  by  exclusion.  With  sym- 
ptoms of  obstruction,  the  surgeon  should  first  examine  the 
rectum,  digitally  and  by  means  of  a  gum-elastic  catheter  ;  if 
these  fail  to  find  any  obstruction,  fluid  may  be  injected  and 
note  taken  of  the  amount  introduced  before  its  return.  The 
passage  of  meconium  in  any  quantity  will  probably  indicate 
obstruction  high  up.  When  evacuations  per  rectum  take  place, 
sweet  oil  may  be  given  by  the  mouth,  and  the  motions  care- 
fully examined  for  its  presence.  Emerson  tried  this  means  ; 
oil  was  administered  twice,  but  nothing  appeared  in  the 
evacuations.  The  character  of  the  vomit  should  be  carefully 
noted  ;  continuous  ejections  without  evidence  of  bile  or 
meconium  will  possibly  prove  one  of  the  best  signs  that  the 
obstruction  is  situated  in  the  upper  part  of  the  duodenum. 

Treatment. — The  continuance  of  the  symptoms,  with  the 
inability  to  arrive  at  a  diagnosis,  will  probably  tempt  the 
surgeon  to  perform  an  exploratory  laparotomy.  Not  much 
harm  can  come  of  it,  nor  much  good  either,  except  that  the 
surgeon  and  the  friends  may  have  the  satisfaction  of  knowing 
that  life  under  no  circumstances  could  be  maintained. 

Perforation  of  tlie  duodemun  from  external  causes. — The 
duodenum,  like  the  stomach  and  other  parta  of  the  intestine, 
may  be  perforated  by  inflammatory  mischief  arising  in  its 
immediate  neighbourhood.     Eolleston  ^  showed   a  specimen 

'  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  ii.  L— 15. 
-  Society's,  Tfwis,  1891,  vol.  xlii.  p.  18G. 


OPERATIONS  295 

before  the  Pathological  Society  of  London  of  a  tubercular 
perinephric  abscess  which  had  ulcerated  into  the  duodenum 
by  two  or  more  openings  situated  about  the  lower  part  of  the 
second  portion  and  the  commencement  of  the  third. 


CHAPTER   XXXIV 

OPERATIONS 


DUODENOSTOMY 
DUODENECTOMY 


nUODENOTOMY 
DUODENOPLASTY 


Duodenostomy. — The  operation  of  establishing  a  permanent 
fistula  in  the  duodenum  in  cases  of  obstruction  at  the 
l^ylorus,  or  of  extensive  disease  in  the  stomach,  has  only  been 
performed  some  few  times.  Theoretically  the  opening  would 
appear  to  be  at  the  best  position  for  feeding  the  patient,  but 
practically  the  operation  proves  much  less  easy  of  execution  than 
jejunostomy  or  gastro-enterostomy,  when  either  of  the  latter  can 
be  adopted  as  a  substitute.  The  operation  has  found  but  little 
favour  with  surgeons,  and,  while  fatal  in  the  few  instances 
in  which  it  has  been  practised,  it  can  hardly  be  considered 
to  have  received  a  fair  trial.  It  was  originally  introduced 
and  practised  by  Langenbuch  ^  in  1879.  In  1883  it  was 
performed  in  this  country  by  Robertson,^  in  1884  by  Southam,^ 
and  Solis-Cohen.^  refers  to  a  fourth  case  operated  upon  by 
Surmay. 

Operation. — The  abdomen  is  opened  by  an  incision  in  the 
middle  line  above  the  umbilicus.  The  pylorus  is  felt  for,  and 
the  duodenum  identified.  The  latter  is  then  brought  up  to 
the  wound  and  secured  there  by  a  circle  of  silk  stitches,  which 
pass  through  the  entire  thickness  of  the  abdominal  parietes, 
but  only  through  the  serous  and  part  of  the  muscular  coats 
of  the  bowel.  When  the  stitches  are  tied,  the  visceral  and 
parietal  serous  surfaces  should  be  perfectly  coapted.  A  stitch 
or  two  is  placed  at  each  extremity  of  the  abdominal  wound  so 
as  to  close  it  to  the  required  extent.     In  the  course  of  a  few 

'  Berliner  klin.  Wochenschrift,  1881,  No.  17,  p.  235. 

'■^  Brit.  Med.  Journ.  1884,  vol.  i.  p.  1146. 

^  International  Encyclopedia  of  Surgery,  vol.  vi.  p.  4 


296  THE   DUODENUM 

days  the  operation  is  completed  by  opening  the  bowel.  la 
Langenbuch's  case  the  operation  was  performed  on  Septem- 
ber 4,  1879,  the  opening  into  the  bowel  was  made  on  the 
11th,  and  the  patient  died  of  exhaustion  on  the  14th.  In 
Eobertson's  case  the  patient  was  greatly  exhausted  at  the  time 
of  the  operation,  and  died  about  twelve  hours  afterwards  from 
shock.  In  Southam's  case,  owing  to  the  very  collapsed  con- 
dition of  the  patient,  the  bowel  was  opened  on  the  third  morn- 
ing, but  death  followed  from  exhaustion  in  the  evening.  At 
the  post  mortem  there  was  no  peritonitis,  and  the  parts  were 
firmly  united. 

The  preparation  of  the  patient,  the  treatment  during  the 
period  between  the  first  and  second  operations,  and  the  after 
treatment  are  in  all  respects  similar  to  what  is  done  in  the 
operation  of  gastrostomy,  reference  to  which  should  therefore 
be  made.     (See  page  23-2.) 

Duodenectomy. — The  operation  of  removing  portions  of  the 
duodenum  has  up  to  the  present  been  still  more  rarely 
practised  than  the  operation  just  described.  The  most 
successful  instance  of  its  performance  is  the  case  already 
quoted  of  Dean's,^  where  a  duodenal  ulcer  was  excised. 

Operation. — The  abdomen  is  opened  and  the  duodenum 
exposed  as  in  the  operation  of  duodenostomy.  The  excision 
of  the  part  and  the  closure  of  the  visceral  wound  will  be 
carried  out  as  already  described  when  referring  to  Dean's  case. 
(See  page  282.) 

Duodenotomy. — The  operation  for  merely  opening  the  duo- 
denum and  then  reclo&ing  the  aperture  exists  more  in  name 
than  in  practice.  The  operation,  however,  is  one  that  would 
be  employed  for  the  removal  of  a  foreign  body. 

Duodenoplasty. — The  operation  in  all  its  details  resembles 
pyloroplasty  (see  page  265).  It  is  employed  for  cicatricial 
stricture  of  the  duodenum.  The  stricture  is  divided  com- 
pletely through  in  the  long  axis  of  the  bowel,  and  the  raw 
edges  reunited  in  the  transverse  axis.  It  has  been  successfully 
performed  by  Lange.     (See  page  292.) 

'^  Brit.  Med.  Journ.  1894,  vol.  i.  p.  1014. 


THE   JEJUNUM   AND    ILEUxAI  297 

SECTION   II 

THE   JEJUNUM   AND   ILEUM 

CHAPTEE  XXXV 

ANATOMY   AND    PHYSIOLOGY 

Anatomy. — The  remaining  part  of  the  small  intestine 
comprises  the  jejunum  and  the  ileum,  the  jejunum  forming 
the  upper  two-fifths  and  the  ileum  the  remainder.  The  two 
portions  run  imperceptibly  into  each  other,  although  at  their 
opposite  extremities  there  are  features  sufficiently  distinctive 
of  each.  The  average  length  of  the  combined  parts  in  the 
adult  is  about  nineteen  feet.  Commencing  at  the  termina- 
tion of  the  duodenum,  on  the  left  side  of  the  second  lumbar 
vertebra,  the  bowel  forms  numerous  convolutions,  and  ends  in 
the  csecum  in  the  right  iliac  fossa.  These  coils  occupy  the 
middle  and  lower  part  of  the  abdomen,  and  are  surrounded 
by  the  large  bowel.  The  jejunum  is  chiefly  situated  in  the 
umbilical  and  left  iliac  regions,  while  the  ileum  mostly  occupies 
the  umbihcal,  hypogastric,  right  iliac,  and  sometimes  the  cavity 
of  the  pelvis.  As  broad  points  of  distinction  between  the  two 
portions,  the  jejunum  is  thicker  in  its  coats,  larger  in  calibre, 
and,  from  its  greater  vascularity,  deeper  in  colour. 

The  mesentery  attaches  the  intestine  to  the  spinal  column, 
the  line  of  connection  being  from  the  left  side  of  the  second 
lumbar  vertebra  obliquely  to  the  right  sacro-iliac  synchondrosis. 
At  its  attachment  to  the  vertebra  it  measures  about  six  inches, 
and  its  breadth  between  the  column  and  the  bowel  averages 
four  inches. 

Structure. — The  wall  of  the  bowel  consists  of  four  coats — 
serous,  muscular,  submucous,  and  mucous. 

The  serous  or  peritoneal  coat  completely  surrounds  the 
gut,  except  at  its  line  of  reflection  to  form  the  mesentery.  At 
this  border  the  vessels  and  nerves  enter  the  bowel,  and  the 
lacteals  leave  it. 

The  muscular  coat  is  made  up  of  two  layers  of  involuntary 
muscle — an  external  and  thinner  one  consisting  of  longitudinal 
fibres,  and  an  internal  and  thicker  composed  of  circular  fibres. 


298  THE   JEJUNUM   AND   ILEUM 

The  submucous  coat  consists  of  loose  cellular  tissue,  connect- 
ing together  the  mucous  and  muscular  coats,  and  serving  as  a 
support  for  the  blood  vessels  prior  to  their  final  distribution, 
and  for  the  larger  lacteal  spaces  at  the  bases  of  the  villi  and 
solitary  glands. 

The  mucous  membrane  which  lines  the  bowel  is  very  loosely 
attached  by  means  of  the  lax  submucous  coat  beneath,  and  is 
thrown  into  numerous  folds  and  projections,  the  valvulse  con- 
niventes  and  villi.  The  surface  of  the  mucous  membrane  is 
covered  by  a  single  layer  of  columnar-shaped  epithelial  cells, 
which  is  uniform  throughout  its  distribution. 

The  following  are  the  structures  contained  within  or  form- 
ing part  of  the  mucous  membrane,  and  which  constitute  the 
special  features  of  this  portion  of  the  small  intestine  : 

Valvulce  conniventes. — These  are  reduplications  of  the 
mucous  membrane.  They  extend  throughout  the  jejunum, 
but  begin  to  disappear  towards  the  middle  of  the  ileum.  Where 
most  typically  represented  they  extend  round  the  bowel  for 
nearly  two-thirds  of  its  circumference,  and  are  about  one- 
third  of  an  inch  in  breadth.  Their  functions  are  to  retard  the 
passage  of  the  chyme  and  to  increase  the  absorptive  surface 
of  the  bowel. 

Villi. —  These  are  minute  vascular  projections  which  ex- 
tend throughout  the  entire  length  of  jejunum  and  ileum, 
becoming  less  marked,  however,  as  the  end  of  the  latter  is 
approached,  and  being  more  or  less  absent  from  the  surface  of 
Peyer's  patches.  Their  intimate  structure  must  be  studied 
elsewhere,  but  it  may  be  briefly  indicated  that  they  contain  an 
intricate  network  of  blood  vessels,  with  a  large  lacteal  running 
down  the  centre.  Their  chief  function  is  concerned  in  the 
process  of  absorption. 

Simple  follicles,  or  crypts  of  Lieberkilhn. — These  are  minute 
tubular  glands  disposed  perpendicularly  to  the  surface  of  the 
mucous  membrane.  They  exist  throughout  the  entire  length 
of  the  intestine  and  are  situated  between  the  villi,  and  only 
around  and  not  upon  Peyer's  patches. 

BrUnner's  glands. — Only  a  few  of  these  glands  are  found  at 
the  commencement  of  the  jejunum,  their  principal  seat  being 
in  the  duodenum.  They  are  located  in  the  submucous  coat, 
and  their  ducts  open  upon  the  surface  of  the  mucous  mem- 


ANATOMY   AND   rilVSIOLOGY  299 

brane.     They  secrete  a  material  which,  as  a  component  of  the 
succus  entericiis,  takes  some  part  m  the  process  of  digestion. 
SoUtarij  (jlands. — These  are  found  throughout  the  small 
intestine,  and  consist  of  lymph  follicles  composed  of  a  dense 
retiform  tissue  containing  numerous  lymph  corpuscles. 

Feyerspntclies  consist  of  collections  of  solitary  glands  which 
form  circular  or  oval  patches  varying  in  length  from  half  an 
inch  to  four  inches.  They  are  found  mostly  in  the  lower  part 
of  the  ileum,  are  most  common  in  early  life,  and  often  dis- 
appear in  old  age.  They  are  usually  free  from  villi  upon  the 
surface,  and  are  surrounded  at  their  margins  with  Lieber- 
kiihn's  glands. 

Vascular  supply. — The  arteries  which  supply  the  small  in- 
testine are  derived  from  the  superior  mesenteric.  Appearing 
at  the  lower  border  of  the  pancreas,  the  trunk  of  the  vessel 
passes  between  the  two  layers  of  the  mesentery.  Here  it 
divides  into  numerous  branches  which  uniting  together  form 
a  series  of  loops  with  their  convexities  turned  towards  the 
bowel.  From  these  loops  other  vessels  are  given  off,  which 
uniting  together  form  another  series  of  arches,  a  process  of 
distribution  which  is  repeated  some  three  or  four  times.  As 
the  border  of  the  bowel  is  reached  the  terminal  branches  take 
a  straight  direction,  passing  round  the  bowel  and  anastomosing 
with  each  other.  The  veins  have  a  similar  course  to  that  of 
the  arteries.  The  main  trunk  joins  with  the  splenic  vein  to 
form  the  portal. 

Lymphatic  or  lacteal  system. — The  radicles  of  the  lympha- 
tics or  lacteals  commence  in  the  villi  and  the  lymph  spaces 
around  the  solitary  glands.  They  unite  together  at  the 
mesenteric  attachment  and  pass  to  the  mesenteric  glands, 
whence  they  proceed  to  form  two  or  three  large  trunks  which 
enter  the  thoracic  duct. 

Nerve  supply.— The  small  intestine  is  supplied  through 
the  sympathetic  nervous  system,  and  through  that  particular 
portion  of  it  which  forms  a  plexus  surrounding  the  artery  of 
the  same  name,  the  superior  mesenteric.  This  plexus  is  a 
continuation  of  the  solar  plexus,  and  is  therefore  placed  in 
connection  with  the  greater  splanchnic  and  the  right  vagus, 
all  of  which  are  intimately  associated  with  the  semilunar 
ganglia. 


3(50  THE   JEJUNUM   AND   ILEUM 

Physiology. — With  the  intricate  process  of  digestion  carried 
on  in  the  jejunum  and  ileum  there  is  no  need  to  deal.  The 
contents  of  the  stomach  as  they  leave  that  organ  do  so  in  the 
form  of  a  thin  pultaceous  chyme,  semi-fluid  in  consistence, 
and  acid  in  reaction.  This  acidity  gradually  diminishes  as 
the  chyme  becomes  mixed  with  the  alkaline  secretions  of  the 
liver,  pancreas,  and  intestinal  glands  until  about  the  middle 
of  the  ileum,  when  the  whole  content  of  the  gut  is  alkaline  in 
reaction,  and  remains  so  until  it  reaches  the  ileo-csecal  valve. 

At  the  lower  end  of  the  ileum  the  content  of  the  bowel 
assumes  a  light  yellow  colour  and  possesses  a  markedly  fascal 
odour. 

The  propulsion  of  the  chyme  through  the  bowel  is  effected 
by  the  peristaltic  or  vermicular  action  of  the  muscular  coa.t. 
The  contraction  may  be  limited  to  sections  only  of  the  canal ; 
it  is  produced  by  the  contents  of  the  intestine  exciting  a  reflex 
action  through  the  intestinal  ganglia.  Other  stimuli  are 
conveyed  through  the  right  vagus  and  greater  splanchnic 
nerves. 


CHAPTEE   XXXVI 


INJURIES.     CONTUSION  :    ACUTE    AND    CHRONIC    ENTERITIS,    ULCERA- 
TION   AND    SLOUGHING,    STRICTURE.       RUPTURE 

Contusion. — Any  severe  blow  upon  the  abdomen  may  cause 
bruising  of  the  bowel,  and  the  injury  inflicted  is  greater  or  less 
according  to  the  force  of  impact,  the  nature  and  shape  of  the 
agent  producing  the  injury,  and  the  condition  of  the  bowels  at 
the  time.  The  kick  of  a  horse  upon  a  loaded  intestine  would 
cause  a  much  severer  contusion  than  a  blow  by  a  fist  upon  an 
empty  bowel. 

A  contusion  in  its  simplest  form  merely  consists  of  a  con- 
gestion of  the  walls  of  the  bowel,  with  rupture  of  some  capillary 
blood  vessels — a  condition  resembling  in  all  respects  a  bruise 
of  any  soft  part.  In  its  severest  form  it  leads  to  sloughing 
and  gangrene  of  the  injured  part.  Between  these  two  ex- 
tremes certain  inflammatory  changes  may  take  place.  If 
acute  inflammation   set  in,  the  symptoms  of  acute  enteritis 


INJURIES  301 

arise ;  and  if  the  inflammatory  process  proceeds  more  slowly, 
evidences  of  chronic  enteritis  become  manifest. 

Symptoms. — No  special  symptoms  can  be  said  to  point  to 
contusion  pure  and  simple.  The  pain  and  collapse  from  which 
the  patient  may  suffer  may  as  likely  indicate  a  rupture  of  the 
bowel  as  it  may  an  uncomplicated  contusion  of  the  abdominal 
wall.  It  is  only  in  the  progress  of  the  case  that  some  clue 
may  be  obtained  to  the  true  nature  of  the  injury.  As  will  be 
pointed  out  in  the  case  of  rupture,  contusion  may  be  unaccom- 
panied by  any  external  manifestation  of  injury  to  the  abdo- 
minal parietes. 

Acute  enteritis. — The  appearance  of  traumatic  enteritis  will 
be  known  by  the  onset  of  symptoms  peculiar  to  that  condition 
when  arising  from  other  causes,  and  for  which  a  fuller  de- 
scription should  be  sought  in  books  on  medicine.  The  appear- 
ance of  such  symptoms  as  offensiveness  of  the  breath,  furring 
and  dryness  of  the  tongue,  aching  and  griping,  nausea  and 
vomiting,  diarrhoea,  and  the  usual  attendants  of  fever  should 
suggest  to  the  surgeon  the  possible  nature  of  the  affection. 

Chronic  enteritis, — Here  also,  as  the  symptoms  significant 
of  this  condition  are  more  frequently  met  with  by  the  physi- 
cian when  arising  from  other  causes,  medical  works  should  be 
consulted.  The  surgeon  may  reasonably  suspect  the  existence 
of  such  a  condition  when  the  patient  begins  to  suffer  some 
days  or  weeks  after  the  accident  from  offensive  evacuations, 
with  excessive  secretion  of  watery  mucus,  griping  pains,  and 
gradual  emaciation  from  imperfect  intestinal  digestion  and 
absorption.  In  less  marked  instances  it  is  sometimes  difficult 
to  distinguish  between  such  a  condition  and  some  local  chronic 
peritonitis. 

Prolonged  chronic  inflammation  may  lead  to  cicatricial 
stricture,  and  this  to  the  symptoms  of  a  gradually  increasing 
obstruction.  A  remarkable  illustration  of  such  a  sequel  to 
contusion  of  the  bowel  is  recorded  by  Braillet,  and  is  referred 
to  by  most  writers  upon  the  subject. 

Case  LX. — Acute  obstruction  from  cicatricial  contraction  of  the  bowel 

folloiving  upon  injury. 

A  man,  about  65,  was  thrown  off  his  horse  on  to  the  handle  of  his 

sword,  and  violentl,y  struck  the  abdomen  two  fingers  off  the  umbihcus. 

He  suffered  acute  pain.     At   the  end  of  foui'  mouths  he   had  frequent 


302  THE   JEJUNUM   AND   ILEUM 

vomitings,  with  pain  like  colic,  especially  at  the  seat  of  the  injured  spot. 
These  were  relieved ;  but  fifteen  months  after  the  accident  the  same 
symptoms  reappeared,  and  increased  until  he  had  stercoraceous  vomiting. 
The  motions  were  at  first  narrow  in  shape,  then  lessened  in  quantity,  until 
absolute  constipation  resulted.  At  this  time  it  was  considered  by  some 
that  the  patient  was  suffering  from  volvulus.  Braillet,  however,  main- 
tained the  opinion  that  the  bowel  had  become  contracted  as  the  result  of 
the  injury.  The  man  died  with  all  the  symptoms  of  acute  obstruction. 
The  post  mortem  revealed  a  contracted  condition  of  the  jejunum  for  six 
inches ;  above  the  stricture  the  bowel  was  dilated  and  contained  the 
metallic  mercury  and  leaden  balls  which  had  been  administered  prior  to 
death.  (From  Poland's  paper  on  '  Contusions  of  the  Abdomen,  '  in  the 
'  Guy's  Hospital  Reports,'  1858,  3rd  series,  vol.  iv.) 

John  Gairdner  reported  a  case  to  the  Medico-Chirurgical 
Society  of  Edinburgh  which  would  appear  to  come  under  the 
same  category.  In  this  instance,  however,  the  fsecal  accumula- 
tion in  the  dilated  portion  of  the  bowel  above  the  stricture 
ed  to  ulceration,  and  this  to  perforation,  with  death  from 
acute  peritonitis. 

Case  LXI. —  Ulceration   and  perforation  above  a  traumatic   stricture 

of  the  jejunum. 
Thomas  Kay,  aged  24,  was  run  over  by  a  loaded  cart,  the  wheel  pass- 
intr  over  the  abdomen.  Pain  was  complained  of  in  the  left  hypochondriac 
reo-ion.  In  about  a  week  after  the  accident  dysenteric  symptoms  came 
on,  with  rigors,  sweating,  occasional  vomiting,  pain  in  the  abdomen,  par- 
ticiilarly  in  the  left  iliac  fossa,  and  dark  foetid  stools.  After  treatment  the 
patient  was  discharged  at  the  end  of  the  third  week,  relieved.  A  month 
after  the  accident,  he  complained  of  severe  griping  pains  in  the  epigas- 
trium, with  considerable  flatulent  distension  in  that  region,  of  dysuria, 
and  of  thirst.  The  stools  were  rather  liquid,  and  small  in  quantity.  These 
symptoms  subsided,  but  only  to  recur  again  a  few  weeks  later.  Three 
months  after  the  accident  he  was  suddenly  seized  with  acute  pain  in  the 
abdomen  :  this  continued  until  he  died,  about  thirteen  hours  later.  The 
post  mortem  showed  a  part  of  the  jejunum  which  was  ulcerated  through  ; 
the  part  of  the  bowel  above  the  ulcer  was  greatly  dilated,  reaching  in 
some  places  to  nearly  the  size  of  the  colon,  and  distended  with  fluid  fecu- 
lent material.  Some  faeces  had  extravasated  into  the  general  peritoneal 
cavity.  (John  Gairdner,  '  Edin.  Med.  and  Surg.  Journ.'  1835,  vol.  xliv. 
p.  281.) 

Ulceration  and  sloughing. — A  blow  which  at  the  time  is 
sufficient  to  devitalise  a  part  of  the  bowel,  will  sooner  or  later 
be  followed  by  separation  of  the  part.  As  this  sequel  to  a 
blow  only  results  from  a  severe  injury,  it  is  not  infrequently 
found  in  association  with  rupture.     One  part  of  the  bowel  mav 


INJURIES  303 

be  torn,  while  another  will  be  badly  contused,  and  it  is 
often  a  matter  of  considerable  difficulty  for  the  surgeon  to 
determine  whether  or  not  the  contused  portion  should  be 
left  to  itself,  or  as  efficiently  dealt  with  as  the  ruptured  part. 
So  many  cases  have  now  been  reported  where  serious  and  fatal 
symptoms  have  come  on  some  days  after  the  injury  and  been 
found  to  be  due  to  a  perforation  through  a  gangrenous  patch 
of  bowel,  that  it  behoves  the  surgeon  to  look  for  and  consider 
well  the  propriety  of  treating  efficiently  any  badly  bruised  part. 

The  consequences  of  ulceration  and  sloughing  of  the  bowel 
may  be  conveniently  considered  under  four  heads. 

First,  where  the  bruised  bowel  becomes  adherent  to  the 
abdominal  parietcs,  and  it  and  the  latter  giving  way  an 
artificial  anus  is  formed.  The  complication  is  a  rare  one, 
because  it  so  seldom  happens  that  the  abdominal  parietes  are 
sufficiently  seriously  injured  to  give  way  by  subsequent  slough- 
ing. In  most  instances,  a  blow  severe  enough  to  devitalise  a 
part  of  the  abdominal  wall  would  almost  certainly  rupture 
the  gut.  Poland,  however,  instances  the  case  of  a  man  who 
was  struck  in  the  abdomen  by  a  splinter  of  shell.  The 
integument  was  bruised.  On  the  sixth  day  the  skin  sloughed, 
and  fseces  passed  through  the  opening. 

Second,  where  the  bowel  becomes  adherent  to  the  abdomi- 
nal parietes,  but  the  latter  remaining  intact,  an  abscess  forms 
at  the  seat  of  contusion.  Such  a  result  ensued  in  the  second 
of  two  cases  of  injury  to  the  intestine  rej^orted  by  Page.^ 
Death  resulted  immediately  from  rupture  of  the  bowel  ten 
days  after  the  accident,  but  the  blow  was  received  in  the  left 
iliac  region,  and  all  the  patient's  earlier  symptoms  were  refer- 
able to  this  region.  At  the  post  mortem,  a  large  collection  of 
pus  was  found  in  the  left  iliac  fossa. 

Third,  where  no  such  adhesion  to  the  parietes  takes  place, 
but  the  separation  of  the  slough  leads  to  a  communication  with 
the  general  peritoneal  cavity,  and  acute  fatal  peritonitis  follows. 
By  far  the  largest  number  of  cases  come  under  this  head. 
The  usual  history  of  the  case  is  that  after  the  patient  has 
recovered  from  the  shock,  the  immediate  result  of  the  injury, 
recovery  apparently  takes  place.  The  pain  gradually  becomes 
less,  vomiting  ceases,  and  the  bowels  move,  and  just  when 

'   Trans.  Clin.  Soc.  Loud,  1888,  vol.  xxi.  p.  251. 


304  THE   JEJUNUM   AXl)    ILEUM 

hopes  are  entertained  that  all  danger  is  past,  the  patient  is 
suddenly  struck  down  with  all  the'  symptoms  of  acute  perfo- 
rative peritonitis.  The  time  at  which  such  perforation  takes 
place  varies.  In  a  case  reported  by  Targett,'  it  occurred  on 
the  fourth  day.  At -the  post  mortem,  the  ileum  was  found 
glued  to  the  spine  on  the  left  side  of  the  fourth  lumbar 
vertebra.  Page  ^  similarly  reports  a  case  of  perforation  on 
the  fourth  day  from  the  date  of  injury.  In  another  case, 
recorded  by  Atlee,^  the  patient  was  doing  well  on  the  tenth 
day  when  he  got  up  to  go  to  stool.  On  returning,  he  was 
tripped  up  by  his  blanket  and  fell ;  immediately  after,  he  was 
seized  with  severe  symptoms  which  proved  fatal  in  two  hours. 
At  the  post  mortem,  a  jagged- edge  hole,  large  enough  to 
admit  the  tips  of  four  fingers,  was  found  in  the  intestine  lying 
to  the  right  of  the  median  line,  midway  between  the  umbilicus 
and  the  pubes. 

Fourth.  Poland,  in  his  well-known  article  already  referred 
to,  gives  three  cases  where  portions  of  the  bowel  were  cast 
off  and  passed  per  rectum.  The  patients  all  recovered.  It  is 
difficult  to  understand  how  this  process  of  separation  has 
been  effected,  except  on  the  assumption  that  the  injured  part 
must  some  time  subsequently  have  become  intussuscepted ; 
and  the  explanation  becomes  the  more  probable  when  it  is 
noted  that  in  each  instance  it  was  a  complete  segment  of 
bowel  that  passed,  measuring  not  less  than  ten  inches.  In  the 
first  case  the  passage  of  the  segment  was  after  *  some  weeks ;  ' 
in  the  second  on  the  eighteenth  day  ;  and  in  the  third,  about 
a  year  after. 

Treatment. — Contusions  of  the  abdomen  giving  rise  to 
serious  symptoms  immediately  after  the  receipt  of  injury 
should  all  receive,  at  first,  the  same  treatment.  Eest,  and 
nothing  by  the  mouth,  should  be  the  rigid  rule  of  practice.  If 
the  collapse  be  so  profound  that  stimulants  appear  impera- 
tively necessary,  these  should  take  the  form  of  brandy  by 
the  rectum  or  ether  subcutaneously.  As  the  primary  col- 
lapse passes  off,  the  question  of  laparotomy  will  arise.  If 
the  indication  is   in  the  direction  of   a  gradual  subsidence 

>  Trans.  Path.  Soc.  Lond.  1887,  vol.  xxxviii.  p.  143. 

-  Trans.  Clin.  Soc.  Lond.  1888,  vol.  xxi.  p.  251. 

»  Medical  Press  and  Circular,  1885,  N.S.  vol.  xxxix.  p.  ICC. 


INJURIES  305 

of  the  acute  symptoms,  then  active  measures  may  be  delayed, 
and  the  patient's  strength  maintained  by  the  administra- 
tion of  nutrient  enemata.  Nothing,  not  even  ice,  should  be 
given  by  the  mouth,  as  everything  taken  into  the  stomach 
is  liable  to  excite  peristalsis  of  the  bowel.  This  method  of 
treatment  must  be  carried  out  as  long  as  possible,  as  long 
indeed  as  the  patient's  strength  appears  likely  to  allow.  To 
more  effectually  obtain  rest  for  the  bowel,  opium  should  be 
added  to  the  nutrient  enemata. 

In  the  event  of  laparotomy  being  performed,  the  greatest 
difficulty  may  arise  in  determining  whether  or  not  the  injured 
part  should  be  excised.  Experience  would  seem  to  teach 
that  when  in  doubt  it  would  be  wiser  to  remove  the  part  than 
leave  it.  As  already  shown,  the  commonest  result  of  slough- 
ing or  gangrene  of  the  bowel  is  fatal  perforative  peritonitis. 
If  in  any  case  the  injury  has  been  severe  enough  to  rupture 
the  bowel  in  one  part,  it  is  the  more  likely  that  a  contusion 
found  elsewhere  will  subsequently  perforate.  Hence  in  these 
particular  instances  the  conditions  may  be  deemed  of  a  more 
critical  nature  than  in  those  of  uncomplicated  bruising. 

The  after  treatment  of  cases  operated  upon  must  be  on 
the  same  strict  lines  of  perfect  rest.  So  long  as  the  patient 
can  live  by  rectal  alimentation,  nothing  should  be  adminis- 
tered by  the  mouth. 

Rupture. — The  same  causes  which  produce  contusion  of 
the  bowel  may  give  rise  to  rupture.  The  severity  of  the  injury, 
and  the  nature  of  the  body  producing  it,  are  the  principal 
factors  in  determining  the  occurrence  of  rupture  in  place  of 
contusion.  Where  in  any  case,  therefore,  the  blow  has  been 
sufficient  to  knock  the  patient  down,  or  dislodge  him  for  some 
feet ;  where  a  fall  has  been  from  some  height ;  where  the 
wheel  of  a  heavy  or  heavily  laden  vehicle  has  passed  across 
the  abdomen  ;  or  where  a  very  tight  squeeze  or  jam  has 
occurred,  suspicions  should  be  entertained,  however  slight 
perchance  may  be  the  symptoms,  that  some  injury  graver 
than  that  of  contusion  has  taken  place.  As  has  already  been 
pointed  out  in  the  case  of  contusion,  so  here  does  it  apply  with 
equal,  if  not  greater  force,  that  the  condition  of  the  bowel 
at  the  time  of  the  accident  material^  affects  the  nature  and 

X 


306  THE   JEJUNUM    AND    ILEUM 

extent  of  the  injury,  a  loaded  intestine  being  more  likely  to 
be  ruptured  than  an  empty  one,  and  the  lesion  itself  graver. 

The  nature  of  the  lesion  produced  in  any  case  may  vary 
in  regard  to  extent,  from  the  size  of  a  small  puncture  through 
which  the  intestinal  contents  will  not  exude,  to  a  complete 
breach  of  continuity.  The  bowel  may  be  ruptured  at  the  point 
of  impact,  or  at  some  distance  from  it.  In  the  former  instance 
there  is  likely  to  be  considerable  contusion  of  the  margins  of 
the  rent,  which  may  be  jagged  and  irregular,  or  more  or  less  of 
the  nature  of  an  incision.  In  the  latter,  while  the  tear  may 
be  clean  cut  or  irregular,  the  margins  of  the  aperture  are 
usually  free  from  bruising.  In  both  cases  there  is  the  possi- 
bility of  some  rent  in  the  mesentery,  a  lesion  the  existence 
of  which  is  usually  indicated  by  the  presence  of  considerable 
intra-abdominal  haemorrhage. 

Kegarding  the  relative  frequency  with  which  the  two  parts 
of  the  small  intestine  are  involved,  it  would  appear  that  the 
ileum  is  somewhat  more  frequently  ruptured  than  the  jejunum. 
In  Poland's  paper  ^  published  in  1858,  thirty  cases  of  ruptured 
small  intestine  are  recorded,  of  which  sixteen  comprised  the 
ileum  and  fourteen  the  jejunum.  In  Croft's  tables  ^  published 
in  1890,  out  of  ten  cases  cohected  between  1873  and  1890, 
seven  were  cases  of  rupture  of  the  ileum  and  three  of  the 
jejunum.  And  out  of  ten  cases  which  I^  have  found  recorded 
since  1890,  six  were  ruptures  of  the  ileum  and  four  of  the 
jejunum.  In  many  reported  cases  it  is  simply  stated  that 
the  small  intestine  was  injured,  without  particularising  the 
region ;  only  those  cases  therefore  have  been  selected  where 
the  position  of  the  rupture  was  stated,  and  confirmed  either 
by  operation  or  at  the  post  mortem.  Cases  also  of  ruptured 
bowel  in  a  hernial  sac  have  not  been  included.  The  only 
practical  value  of  these  statistics  is  to  show  that,  while  the 
ileum  is  slightly  more  often  injured  than  the  jejunum,  the 
difference  is  not  sufficiently  marked  to  warrant  the  surgeon,  at 
the  time  of  operation,  investigating  more  carefully  one  region 
than  the  other.     There  is  nothing  to  show  that  the  ileum  is 

'  Gm/s  Hospital  Beports,  1858,  3rd  series,  vol.  iv.  p.  143. 
^  Trans.  Clin.  Soc.  Loncl.  1890,  vol.  xxiii.  p.  147. 

^  Cases  of  raptured  jejunum:    White,   Hood,  Battle,  Maylard.     Cases  of 
ruptured  ileum  :  Conley,  Griilith,  Templeman,  Eoekwell,  Esson,  Wiggin. 


PLATE    XIV. 


Fig-.  44.— Rupture  of  Jejunum.— The  rupture  was  seated  about  twenty  inches  fror 
the  duodenum,  and  was  the  result  of  a  fall  across  a  bar.     i,lV.I.£M.,  Glas.) 


nUPTUlJE  307 

more  frequently  injured  in  one  part  than  another,  but  in  the 
case  of  the  jejunum  it  is  the  upper  part  or  that  nearest  its 
commencement  that  most  frequently  suffers.  The  left  hypo- 
chondriac region,  then,  is  always  a  part  to  be  carefully  explored. 
Symptoms. — The  immediate  result  of  the  injury  is  to 
produce  more  or  less  shock.  The  degree  of  the  shock  pro- 
duced is  frequently,  however,  no  indication  of  the  severity  of 
the  lesion.  So  far  indeed  does  this  appear  from  being  in 
any  sense  a  symptom  peculiar  to  rupture,  that  it  seems 
reasonable  to  believe  that  it  is  in  some  instances  the  result 
rather  of  a  powerful  emotional  effect  produced  by  the  con- 
sciousness of  a  severe  injury,  than  of  any  special  lesion 
acting  in  a  particular  way.  Considered  therefore  in  this 
aspect,  shock  must  often  be  looked  upon  as  a  symptom 
not  so  much  of  any  grave  effects  of  the  injury  as  of  a 
peculiar  nervous  susceptibility  possessed  by  the  patient. 
As  illustrating  this  view  of  the  nature  of  shock,  a  case 
recorded  by  Stimson^  may  be  instanced.  A  patient  was  shot 
by  a  revolver ;  the  shock  was  so  profound  that  when  the 
patient  was  admitted  into  the  hospital  he  was  apparently 
moribund.  On  making  an  examination,  the  bullet  was  found 
only  to  have  perforated  the  patient's  clothes,  the  skin  of 
the  abdomen  being  untouched.  On  the  other  hand  not  a  few 
cases  are  recorded  where  grave  lesions  have  occurred,  but 
there  has  been  an  enth-e  absence  of  shock.  Thus  in  a  case 
reported  by  Conley  ^  there  was  no  sign  of  shock,  although  the 
blow  by  a  flying  piece  of  plank  from  a  circular  saw  had  been 
sufficient  to  throw  the  patient  several  feet ;  later  in  the  day 
signs  of  shock  came  on,  and  after  three  days  death  occurred, 
when,  at  the  post  mortem,  a  rent  about  an  inch  long,  with 
ragged  and  contused  edges,  was  found  in  the  ileum.  Another 
case  is  recorded  by  Eobson.^  A  man  fell  about  ten  feet, ;  he 
was  stunned  for  a  minute,  but  afterwards  got  up  and  walked 
a  distance  of  two  miles.  He  died  on  the  third  day,  when  a 
rent  an  inch  long  was  found  in  the  small  intestine.  It  will 
be  seen  from  these  cases  that  but  little  diagnostic  value  can 
be  attached  to  the  symptom  of  shock. 

'  Annals  of  Surgery,  1894,  vol.  xix.  p.  91. 

-  Boston  Med.  and  Surg.  Journ.  1890,  vol.  cxxiii.  p.  22.5. 

^  Trans.  Clin.  Soc.  Land.  1888,  vol.  xxi.  p.  122. 

X  2 


308  THE   JEJUNUM   AND    ILEUM 

Pain  is  almost  always  present,  although  it  may  vary 
considerably  in  severity  and  situation.  If  masked  at  first  by 
shock,  it  usually  supervenes  later,  when  it  may  be  of  a  most 
acute  character,  causing  the  patient  to  *  double  up.'  Pain, 
when  thus  acutely  felt  either  immediately  after  the  injury 
or  as  the  primary  shock  passes  off,  is  aggravated  by  move- 
ment, respiration,  and  physical  examination.  It  is  often 
complained  of  most,  immediately  over  the  seat  of  the  rupture  ; 
at  other  times  it  radiates  over  the  whole  abdomen,  and  when 
thus  diffused  it  fails  to  afford  any  clue  as  to  the  probable 
situation  of  the  lesion.  To  secure  immobility  the  parietal 
muscles  are  thrown  into  contraction,  so  that  the  surface  of 
the  abdomen  often  appears  rigid  and  retracted. 

Vomiting,  while  not  a  constant  symptom,  is  more  frequently 
present  than  absent,  and  often  occurs  immediately  after 
receipt  of  the  injury.  "When  present  it  usually  persists  and, 
in  those  cases  in  which  recovery  does  not  lake  place,  con- 
tinues until  death.  The  presence  of  blood  in  the  vomit  is 
rarely  met  with  ;  when  present,  it  is  likely  to  come  from 
rupture  high  up  in  the  jejunum.  It  must  be  remembered, 
however,  that  the  presence  of  blood  is  much  more  significant 
of  rupture  of  the  stomach  than  of  the  small  intestine. 

The  state  of  the  pulse  and  the  temperature  is  more  de- 
pendent upon  the  amount  of  shock  than  upon  the  actual  injury 
done.  When  the  shock  is  at  all  severe,  the  pulse  may  become 
feeble,  quick,  irregular,  and  small,  while  the  temperature  may 
sink  below  normal.  Piespiration  is  sometimes  quick,  laboured, 
and  shallow.  It  is  painful  because  the  movements  involved 
are  apt  to  act  upon  the  injured  parts.  It  is  noticed  therefore 
that  breathing  is  principally  thoracic. 

The  loss  of  the  usual  area  of  liver  dulness  is  one  of  the 
most  important  symptoms  of  rupture  of  some  part  of  the 
abdominal  alimentary  canal.  It  is  as  much  significant  of 
rupture  of  the  stomach  or  large  intestine  as  it  is  of  the  small. 
It  indicates  that  gas  has  escaped  and  probably  is  escaping  from 
the  perforated  viscus.  When  it  exists  to  any  large  extent,  the 
abdomen  becomes  distended  and  tympanitic.  In  exceptional 
instances,  it  has  been  known  to  make  its  way  into  the  cellular 
tissues  of  the  abdominal  parietes  and  other  more  distant  parts. 
Thus  in  a  case  of  ruptured  ileum  about  three  inches  fiora  the 


RUPTURE  309 

ileo-caecal  valve,  recorded  by  Templeman/  emphysema  occurred 
in  the  front  of  the  abdomen  and  chest,  in  the  neck  and  face, 
the  shoulder  and  upper  part  of  both  arms,  the  scrotum  and 
penis,  and  the  upper  part  of  both  thighs.  The  scrotum  and 
penis  were  enormously  enlarged,  being  three  or  four  times 
their  normal  size. 

Eetention  of  urine,  while  a  symptom  of  no  significance,  is 
occasionally  present.     Defsecation  sometimes  takes  place. 

In  general  appearance  the  patient  is  frequently  much 
distressed,  with  pallor  of  face  and  anxious  expression.  The 
skin  surface  may  be  pale  and  cold,  with  beads  of  perspiration 
on  the  forehead.  The  skin  over  the  abdomen  frequently 
shows  no  evidence  whatever  of  the  grave  lesion  produced 
deeply.  If  not  restless,  he  will  lie  in  bed  with  his  knees 
drawn  up  and  thorax  raised  so  as  to  relieve  any  pressure 
upon  the  abdominal  contents.  Great  thirst  is  frequently 
complained  of. 

As  the  primary  shock  passes  off  and  the  patient  becomes 
more  conscious,  symptoms  of  acute  general  peritonitis  begin 
to  appear  in  from  twelve  to  twenty-four  hours  from  the  time 
of  receipt  of  the  injury. 

Case  LXII. — Bu^pture  of  the  jejunum  at  its  middle.    Death  in 
tiventy -eight  hours. 

A  miner  aged  17  was  crushed  in  a  pit.  When  first  seen,  at  8.45  a.m.,  he 
was  in  a  very  much  collapsed  condition,  the  pulse  at  the  wrist  being  almost 
imperceptible.  He  lay  on  the  bed  with  his  knees  drawn  up,  and  complained 
of  severe  abdominal  pain.  The  abdomen  was  rigid  and  boardlike,  but 
presented  no  bruise.  The  tenderness  and  rigidity  were  most  marked  in 
the  left  umbilical  and  lumbar  regions.  No  abdominal  dulness  could  be 
detected,  and  the  liver  dulness  was  absent.  At  10.45  a.m.  the  abdomen  had 
become  distended,  and  early  in  the  afternoon  vomiting  set  in,  at  first 
gastric,  then  bilious,  but  never  bloody  or  faecal.  The  next  morning,  at 
9.45,  he  passed  a  normal  stool  and  died  immediately  afterwards,  twenty- 
eight  hours  after  the  injury.  At  the  post  mortem,  the  intestines  were 
found  covered  with  a  fibrinous  exudation,  on  removal  of  which  the  vessels 
were  seen  to  be  much  injected.  Just  to  the  left  of  the  spine  the  small 
intestine  was  ruptured  about  the  middle  of  the  jejunum.  The  rupture  was 
transverse,  and  involved  the  Avhole  of  its  circumference,  with  the  excep- 
tion of  about  one -eighth  of  an  inch  at  the  attachment  of  the  mesentery. 


'  Brit.  Med.  Journ.  1893,  voLi.  p.  401. 


310  THE    JEJUNUM    AND    ILEUM 

The  bowel  itself  was  cnisbed  only  for  a  distance  of  about  a  quarter  of  an 
inch  on  each  side  of  the  rent,  the  edges  of  which  were  thickened  and 
cedematous.     (White,  '  Brit.  Med.  Journ.'  1894,  vol.  i.  p.  1077.) 

Prognosis. — "With    but   very   few   exceptions    a    ruptured 
bowel  which  is  left  unoperated  upon  leads  sooner  or  later  to 
a  fatal   result.     Out  of  Poland's  thirty-eight  cases,  twenty- 
six  died  within  forty-eight  hours.     Injuries  to  the  jejunum 
do  not  seem   more  rapidly   fatal  than  those   to   the  ileum. 
The   remote   possibilities  of   a  natural   cure    depend   either 
upon   adhesions    forming    between    the   rupture   and    some 
neighbouring  part,  or  the  formation  of  a  localised  abscess, 
which,  bursting  externally,  produces  a  fsecal  fistula.     In  cases 
operated  upon,  the  chances  of  success  largely  depend  upon 
the   time   which  has   elapsed   between   the   injury   and   the 
operation.     Where  this  is  short,  and  before  the  progress  to 
any  marked  extent  of  general  peritonitis,  a  reasonable  hope 
of  recovery  may  be  entertained.     In  1890  Croft  estimated 
that  recoveries   after  operation   were  one  in  fourteen.      In 
1894  Battle  ^  was  able  to  record  that  since  Croft's  statistics 
were  published  in  1890,  he  had  collected  fifteen  cases  with 
seven  recoveries.     Shock  after  the  operation,  and  peritonitis, 
are  the  two  most  cogent  factors  in  causing  death.     The  pre- 
vention of  these  therefore  must  be  the  surgeon's  chief  aim  if 
success  is  to  be  looked  for. 

Treatment. — Eecognising  the  almost  uniformly  fatal  termi- 
nation of  these  cases  when  left  to  the  unaided  efforts  of 
nature,  exploratory  laparotomy  should  be  performed  as  soon  a  s 
the  patient  has  sufficiently  recovered  from  the  primary  shock. 
During  the  early  period  the  patient  should  be  kept  at 
rest  in  bed,  warmth  applied  to  the  body  generally,  and  hot 
fomentation  to  the  surface  of  the  abdomen.  If  stimulants  are 
deemed  necessary,  brandy  should  be  given  by  the  rectum,  or 
ether  by  subcutaneous  injection.  Nothing  should  be  adminis- 
tered by  the  mouth. 

In  performing  the  operation,  the  abdominal  incision 
should  be  made  in  the  median  line  above  the  umbilicus. 
This  admits  of  examination  of  the  stomach  and  duodenum, 
as  well  as  of  the  upper  part  of  the  jejunum.     If  necessary  for 

'  Brit.  Med.  Journ.  1894,  vol.  i.  p.  963. 


IIUPTURE  311 

a  more  complete  examination  or  for  easier  and  more  efficient 
treatment  of  the  rupture,  the  incision  may  be  enlarged  down- 
wards or  laterally. 

On  opening  the  peritoneal  cavity,  the  escape  cf  gas  or 
ficcal  matter  will  confirm  the  diagnosis.  A  systematic  and 
careful  search  for  tlie  ru[)ture  should  then  be  made.  A  loop 
of  intestine  being  withdi-awn  from  the  abdominal  cavity  and 
held  by  an  assistant,  one  end  is  traced  until  it  leads  to  its 
fixed  extremity,  which  may  either  prove  to  be  the  duodenal 
above  or  the  csecal  below.  This  portion  of  the  bowel,  as  it  is 
drawn  out  through  the  parietal  wound,  should  be  carefully 
projected  by  the  assistant  with  warm  sponges  or  cloths,  and 
as  soon  as  its  examination  is  completed  it  should  be  carefully 
replaced  before  a  similar  process  is  gone  through  with  the 
other  end  of  the  loop. 

When  the  rupture  has  been  found,  the  surgeon  has  to 
decide  what  method  he  will  adopt  in  treating  it,  whether  he 
will  elect  to  (1)  stitch  it  up,  (2)  to  resect  it,  or  (3)  to  attach 
it  to  the  parietal  wound  and  so  form  a  fsecal  fistula  or  an 
artificial  anus. 

(1)  Stitching  up  the  wound  should  only  be  adopted  when 
the  rupture  is  small  or  of  the  nature  of  an  incision  with  non- 
contused  edges.  A  series  of  interrupted  Lembert  sutures 
should  be  inserted.  The  true  guidance  for  the  employment 
of  this  method  is  when  the  application  of  sutures  can  be 
efi'ected  without  seriously  narrowing  the  calibre  of  the  canal. 
A  successful  case  by  this  method  is  recorded  by  Williamson.' 
The  operation  was  performed  thirty  hours  after  the  accident. 
The  rupture  was  found  at  the  junction  of  the  jejunum  and  the 
duodenum. 

(2)  Excision,  with  reunion  of  the  divided  extremities,  or 
some  form  of  lateral  anastomosis,  must  be  considered  when  the 
simple  method  above  described  cannot  be  carried  out.  In 
other  words,  it  should  be  adopted  when  the  wound  is  large, 
or  its  edges  so  contused  that  sloughing  or  gangrene  is  pro- 
bable. By  this  method  of  enterectomy  and  circular  suture 
Wiggin  2  succeeded  in  treating  a  case  of  ruptured  ileum. 
Although  the  rupture  was  very  small,  the  contusion  of  the  wall 

'  Brit.  Med.  Journ.  1895,  vol.  u  p.  200. 

-  New  York  Med.  Journ.  1894,  vo^  lix.  p.  68. 


Blti  THE   JEJUNUM   AND   ILEUM 

around  tlie  rupture  was  so  severe  'and  extensive  that  it  was 
deemed  advisable  to  excise  six  inches.  In  the  second  of 
Croft's  two  successful  cases '  this  method  of  treating  the  rup- 
ture was  adopted. 

(B)  The  formation  of  an  artificial  anus  is  the  wiser  course 
to  adopt  when  portions  of  the  bowel  distal  to  and  distant  from 
the  seat  of  rupture  are  sufficiently  badly  contused  to  render 
it  advisable  to  give  the  parts  complete  rest.  The  temporary 
diversion  of  the  faeces  through  the  artificial  aperture  gives 
greater  chance  of  repair  to  the  contused  parts,  and  lessens 
therefore  the  risk  of  subsequent  perforation.  In  the  first  of 
Croft's  cases  this  course  was  adopted. 

The  finding  of  a  single  rupture  should  not  satisfy  the 
surgeon  that  that  is  the  sole  lesion  present ;  the  possibility  of 
a  second  elsewhere  must  be  remembered,  and  also  the  existence 
of  badly  contused  areas.  Further,  the  mesentery  and  omentum 
should  always  be  carefully  looked  to  ;  especially  should  this  be 
done  when  there  is  evidence  of  intra-abdominal  haemorrhage. 
It  is  usually  from  some  torn  vessel  either  in  the  mesentery  or 
omentum  that  bleeding  most  freely  takes  place.  In  addition 
to  the  injury  to  the  bowel  and  its  attachments,  it  is  necessary 
to  remember  the  possibility  of  grave  lesions  of  the  neighbour- 
ing viscera. 

When  the  rupture  or  any  other  lesion  has  been  dealt  with, 
the  peritoneal  cavity  must  be  thoroughly  cleansed  either  by 
swabbing  or  by  washing  out.  This  needs  to  be  all  the  more 
efficiently  done  if  peritonitis  has  commenced  or  fsecal  extra- 
vasation has  been  marked.  In  these  latter  cases  the  abdominal 
cavity  should  be  drained.  As  accumulations  of  fsecal  or  in- 
flammatory material  are  more  liable  to  take  place  in  the 
pelvis,  the  tube  should  lead  well  down  into  that  cavity ;  and 
where  this  cannot  be  effectually  done  from  the  wound  above 
the  umbilicus,  a  second  incision  should  be  carried  through  the 
parietes  below  it. 

It  has  happened  that  while  there  has  been  distinct  evidence 
of  rupture,  from  the  extravasation  of  foreign  material  into 
the  abdominal  cavity,  the  lesion  could  not  be  found.  Such 
was  the  case  in  a  patient  treated  successfully  by  Parker.^ 

'   Trans.  Clin.  Soc.  Land.  1890,  vol.  xxiii.  p.  141. 
^  Aymals  of  Surgery,  1893,  vol.  xvii.  p.  590. 


PUNCTURED   AND   INCISED   AVOUNDS  313 

The  peritoneal  cavity  was  freely  irrigated  and  then  carefully 
packed  with  gauze.  Each  piece,  one  yard  long  by  sixteen 
inches  wide— of  which  six  were  used — was  placed  between  the 
folds  of  the  intestine,  which  were  lifted  up  out  of  the  pelvic 
cavity,  this  latter  being  filled  with  gauze.  The  following  day 
an  anaesthetic  was  administered,  the  gauze  removed,  and  the 
cavity  re-stuffed.  This  was  repeated  some  three  or  four  times, 
when  the  parts  began  to  contract  and  soon  completely  closed. 
The  treatment  after  operation  for  rupture  is  that  carried 
out  in  all  similar  instances  of  intra-abdominal  operation, 
rest  and  rectal  alimentation  being  the  primary  requisites. 


CHAPTEE  XXXVII 

INJURIES  (continued),     punctured  and  incised  wounds 

While  wounds  of  this  nature  are  usually  severer  in  their 
effects  upon  the  jejunum  and  the  ileum  than  upon  the  large 
bowel,  the  difference  in  other  respects  is  hardly  sufficient  to 
necessitate  a  separate  discussion  of  each  region.  It  is  proposed 
therefore  to  treat  them  together,  noting  such  points  of  dis- 
tinction in  the  pathology,  symptoms,  and  treatment  of  each  as 
may  seem  necessary. 

From  a  purely  clinical  aspect,  punctured  or  incised  wounds 
of  the  bowel  practically  resolve  themselves  into  what  is  more 
broadly  comprised  in  similar  wounds  of  the  abdomen.  A 
patient  who  has  received  a  punctured  wound  in  this  region, 
may  present  symptoms  which  in  no  way  indicate  whether 
(1)  the  parietes  have  only  been  incompletely  penetrated  or 
whether  (2)  there  has  been  complete  perforation,  or  whether 

(3)  such  perforation  has  injured  the  bowel  only  slightly  or 

(4)  severely. 

It  has  been  a  fruitful  source  of  discussion  in  more  recent 
times  to  determine  what  attitude  the  surgeon  should  adopt 
in  those  cases  where  the  symptoms  are  not  sufficient  to  indicate 
the  true  nature  and  extent  of  the  lesion.  This  is  a  matter, 
however,  which  will  be  dealt  with  when  considering  the  ques- 
tion of  treatment. 


314  THE   INTESTINES 

Nature  of  lesion  produced. — 1.  The  injury  to  the  imrictes. — 
The  shape  and  extent  of  the  wound  in  the  abdominal  wall  will 
depend  upon  the  nature  of  the  agent  causing  the  injury,  the 
force  with  which  it  acted,  and  the  direction  and  distance  from 
which  it  came  ;  or,  in  the  case  of  stationary  objects,  the  distance 
from  which  the  individual  had  fallen.  In  but  few  cases  is 
there  liable  to  be  much  gaping  of  the  parts,  and  therefore  with- 
out the  hernial  protrusion  of  the  bowel  or  the  escape  of  its 
contents,  it  may  often  prove  difficult,  if  not  impossible,  to 
decide  from  external  appearances  whether  or  nofe  the  wall  has 
been  completely  perforated. 

We  have,  however,  here  to  deal  only  with  actual  instances 
of  complete  perforation.  A  deliberate  stab  with  a  knife  may 
produce  an  incision  no  longer  than  the  breadth  of  the  blade ; 
but  if  this  be  plunged  in  or  withdrawn  obliquely,  a  much 
larger  wound  would  be  produced.  The  lesion  caused  by  a 
small,  round,  sharp-pointed  body,  such  for  instance  as  a  stiletto, 
does  not  as  a  rule  inflict  an  injury  of  any  magnitude  ;  indeed 
the  contraction  of  the  strong  abdominal  muscles  around  the 
narrow  channel  of  penetration  reduces  it  to  such  an  extent 
that  these  frequently  prove  the  most  deceptive  cases. 

The  nature  of  the  agent,  and  the  circumstances  under 
which  it  existed  or  was  used,  should  be  well  considered  in 
framing  any  opinion  as  to  the  possible  extent  of  the  lesion, 
however  opposed  in  other  respects  might  be  the  suggestions 
conveyed  by  the  external  appearances  of  the  wound.  Blunt- 
pointed  bodies,  such  as  spikes  of  palings,  stakes,  &c.,  which 
pierce  the  abdomen  in  cases  of  falls  from  a  height,  produce 
lacerated  and  contused  perforations. 

2.  hijuvies  to  the  bowel. — Whatever  the  nature  of  the 
agent  inflicting  the  injury,  the  extent  of  the  lesion  will  be 
considerably  affected  by  the  state  of  the  bowel  at  the  time.  If 
distended,  it  is  more  likely  to  be  gravely  involved  than  in  the 
opposite  condition. 

The  bowel,  like  the  parietes,  may  be  incised,  punctured 
or  more  or  less  torn  according  to  the  nature  of  the  agent 
producing  the  wound.  In  the  case  of  incised  wounds,  the 
resulting  aperture  varies  according  to  the  direction  of  the 
incision ;  when  this  is  longitudinal  or  parallel  to  the  axis  of 
the  bowel,  a  larger  opening  will  probably  take  place  than  if 


PUNCTURED   AND    IN'CISEL)    WOUNDS  '6ir> 

the  cut  has  heen  a  transverse  one.  The  circular  muscle  of  the 
intestmal  coat  appears  to  have  a  more  powerful  effect  in 
causing  the  wound  to  gape  than  the  longitudinal.  There 
is  therefore  a  grtater  liability  of  escape  of  the  bowel  contents 
in  the  one  case  than  in  the  other.  In  small  punctured 
wounds,  the  contraction  of  the  surrounding  muscle  fibres 
may  almost  obliterate  the  aperture.  In  many  instances  there 
is  prolapse  of  the  lax  mucous  membrane,  so  that  it  forms  a 
hernial  protrusion  through  the  aperture,  the  result  of  which 
is  to  establish  a  fistulous  communication  with  the  general 
peritoneal  cavity.  Multiple  lesions  are  always  possible  ;  either 
the  same  part  may  be  transfixed,  presenting  therefore  two 
opposite  orifices,  or  two  or  more  independent  coils  may  be 
similarly  injured. 

The  escape  of  fsecal  material  is  more  liable  to  happen  in 
wounds  of  the  small  than  of  the  large  intestine,  because  of 
the  more  liquid  condition  of  the  contents  of  the  former. 
Leakage  will  naturally  be  more  probable  in  cases  of  a  full 
than  of  an  empty  bowel. 

Symptoms. — As  already  indicated,  the  difficulties  connected 
with  determining  whether  in  any  given  case  the  bowel  has 
been  injured  are  often  very  great.  It  might  almost  with 
truth  be  said  that  unless  gas  or  fascal  material  exudes  from 
the  abdominal  wound  or  from  a  prolapsed  portion  of  bowel, 
there  are  no  other  symptoms  at  the  time  of  the  injury,  or  very 
shortly  after  it,  which  would  lead  to  the  certain  diagnosis  of 
injured  intestine. 

Shock  is  most  variable,  indicating  on  the  one  hand,  as  it 
may,  a  purely  emotional  effect  where  no  gross  lesion  exists, 
and  on  the  other  an  injury  so  severe  that  a  fatal  result  must 
almost  inevitably  accrue.  Where  shock  is  not  sufficient  to 
mask  other  symptoms,  the  immediate  result  of  the  injury 
may  be  to  cause  acute  abdominal  pain,  followed  by  vomiting 
and  possibly  some  movement  of  the  bowels.  Blood  may  be 
passed  2^er  rectum,  but  this,  when  it  occurs,  is  usually  some 
little  time  after.  One  of  the  most  reliable  symptoms,  and 
one  which  by  some  is  considered  almost  pathognomonic,  is 
tympanites.  Its  presence  therefore  at  an  early  period  should 
excite  the  gravest  fears  that  the  bowel  has  been  opened. 

When  later  symptoms  arise,  they  will  usually  be  those 


316  THE    INTESTINES 

indicative  of  peritonitis,  arising,  if  not  directly  from  the 
traumatism,  indirectly  from  the  extravasation  or  escape  of 
faecal  material  into  the  peritoneal  cavity.  In  some  instances 
the  symptoms  at  the  outset  are  so  slight  that  it  is  reasonably 
doubted  whether  any  grave  lesion  can  have  been  inflicted,  yet 
in  the  course  of  a  few  days  the  patient  is  suddenly  struck 
down  with  what  soon  proves  to  be  acute  general  peritonitis. 
The  explanation  of  this  is  the  giving  way  of  certain  adhesions 
which,  for  the  short  time  being,  had  been  sufficient  to  prevent 
leakage  at  an  earlier  period. 

In  cases  of  much  loss  of  blood,  the  increasing  pallor  of 
the  face  and  the  weak,  compressible  pulse  soon  indicate  the 
nature  of  the  injury.  Either  blood  has  escaped  or  is  escaping 
from  the  wounded  surface  of  the  bowel,  or  it  is  coming  from 
a  severed  mesenteric  vessel.  When  the  quantity  of  blood  lost 
is  large,  it  is  more  commonly  from  the  latter  source. 

Prognosis. — With  often  so  little  definite  knowledge  gained 
from  the  symptoms  as  to  what  is  the  true  nature  of  the  lesion, 
an  opinion  at  the  outset  regarding  the  future  issue  of  any 
case  becomes  impossible.  If,  however,  we  reason  on  certain 
definite  assumptions,  we  can  then  frame  a  prognosis  ;  for  ample 
experience  is  forthcoming  to  show  what  is  liable  to  happen 
in  any  case  where  no  surgical  measures  are  adopted. 

In  the  first  place,  then,  if  faeces  or  gas  escape  from  the 
parietal  wound,  one  of  two  things  must  happen  :  either  the 
patient  will  shortly  die  of  peritonitis,  or  adhesions  will  form 
between  the  visceral  and  parietal  apertures,  and  a  faecal 
fistula  resu't.  The  probabilities  are  all  in  favour  of  the 
former. 

Where,  again,  the  bowel  has  been  opened  in  a  distended 
condition,  extravasation  will  almost  certainly  occur,  resulting 
in  fatal  peritonitis.  On  the  other  hand,  incision  or  puncture 
of  collapsed  intestine  may  result  in  the  rapid  formation  of 
adhesions  which,  in  thus  occluding  the  orifice,  will  effectually 
form  a  barrier  to  the  escape  of  foreign  material.  An  injury 
to  the  large  bowel  in  a  collapsed  condition  is  still  more  likely 
not  to  be  followed  by  any  leakage  than  in  the  case  of  the 
small. 

It  need  hardly  be  pointed  out  that  the  nature  of  the  agent 
producing  the  injury  must  largely  affect  the  prognosis  ;  for 


PUNCTUKED   AND   INCISED   WOUNDS  317 

the  larger  the  wound  inflicted,  the  greater  the  probability  that 
untoward  conditions  must  arise.  However  slight  therefore 
the  symptoms  at  the  time  of  the  injury,  a  graver  prognosis 
needs  to  be  formed  where  the  agent  has  been  a  sword  or  a 
broad -bladed  knife  than  where  it  has  been  of  the  nature  of  a 
small,  narrow,  sharp-pointed  body. 

There  is  much  to  show  that  operation  performed  before 
the  onset  of  peritonitis  may  prove  successful.  Stimson's  case, 
narrated  below,  illustrates  the  good  result  following  laparotomy ; 
Puzey  ^  also  records  a  case  of  multiple  stab  wounds  of  the 
small  intestine.  Some  of  the  wounds  were  closed  by  the 
Czerny-Lembert  suture ;  but  owing  to  the  damage  done  to  a 
part  of  the  mesentery  and  the  portion  of  the  bowel  to  which 
it  was  connected,  about  ten  inches  of  the  intestine  had  to 
be  removed.  The  divided  ends  were  united  by  a  Murphy's 
button.     The  patient  made  a  good  recovery. 

Treatment. — Enough  has  been  said  in  discussing  the  sym- 
ptoms and  prognosis  of  these  wounds  to  show  how  difficult 
must  be  the  question  of  treatment.  To  know  that  nature  is 
capable  of  executing  repair  and  not  to  know  in  what  particular 
instances  she  can  do  so,  sums  up  the  sole  difficulty  in  which 
the  surgeon  finds  himself.  It  would  be  comparatively  easy 
to  say  what  should  be  the  treatment  if  the  lesion  was  precisely 
known.  But  in  the  large  majority  of  instances  we  know 
at  the  outset  little  more  than  that  the  abdominal  wall  has 
been  either  partially  or  completely  penetrated.  Discussing 
therefore  the  treatment  from  the  clinical  standpoint,  the  first 
question  which  always  presents  itself  is,  are  we  to  stand  by 
and  wait  to  see  what  nature  will  do,  acting,  for  the  time  being, 
on  the  broad  principles  of  rest ;  or  are  we  to  probe  the 
matter  to  the  bottom,  and  satisfy  ourselves  what  is  the  nature 
of  the  lesion,  if  such  there  be  ?  To  have  suggested,  much 
less  to  have  adopted,  the  latter  course  some  years  ago,  would 
have  been  deemed  meddlesome,  if  not  actually  bad,  surgery. 
But  is  this  likely  to  be  the  opinion  of  modern  surgeons  ? 
I  cannot  venture,  on  the  basis  of  my  own  limited  experience 
of  these  cases,  to  offer  any  opinion ;  but  if  the  practice  and 
teaching  of  those  surgeons  whose  experiences  have  been  amply 
sufficient  to  warrant  the  foundation  of  a  definite  practice  may 

'  Brit.  Med.  Journ.  1896,  vol.  i.  p.  1030. 


318  THE    INTESTINES 

be  accepted,  then  it  would  appear  that  the  right  course  to  adopt 
is  not  to  leave  the  issue  to  the  vague  and  uncertain  possi- 
bilities of  nature,  but  to  actively  interfere. 

It  may  then  be  considered  that  the  proper  practice  to 
adopt,  in  all  cases  of  pierforating  abdominal  wound,  is  to  probe 
the  wound,  ascertain  its  direction  and  extent,  and,  if  found  to 
perforate  the  parietes,  to  proceed  at  once  to  open  the  abdomen 
and  explore  its  contents.  Where  there  is  any  difficulty  in 
passing  the  probe,  as  there  may  be  from  the  contraction  of 
the  abdominal  muscles  producing  some  deviation  of  the  original 
track,  McBurney's  suggestion  should  be  carried  out.  The 
wound  should  be  opened  up,  beginning  with  the  superficial 
tissues,  and  then  the  walls  split,  layer  by  layer,  until  it  is 
rendered  certain  that  complete  perforation  has  taken  place. 

What  treatment  the  bowel  should  receive  will  naturally 
depend  upon  the  nature  and  extent  of  the  lesion.  A  simple 
incision  of  limited  extent,  or  a  perforating  wound,  will  need 
little  more  than  careful  stitching  with  Lembert  sutures. 
Complete  section  of  the  canal  must  be  treated  by  circular 
suture,  or  by  one  of  the  numerous  methods  now  in  use  for 
intestinal  anastomosis.  It  may  be  considered  proper  to  stitch 
the  bowel  to  the  parietal  wound,  and  so  form  for  the  time 
being  a  faecal  fistula  or  an  artificial  anus,  which  can  be  sub- 
sequently dealt  with.  A  careful  investigation  of  the  whole 
length  of  the  canal  should  always  be  made,  as  multiple  lesions 
are  not  infrequent.  As  soon  as  the  surgeon  has  satisfied 
himself  that  all  lesions  have  been  efficiently  dealt  with,  whether 
they  are  only  of  the  bowel  or  of  the  mesentery  also,  the  peri- 
toneal cavity  should  be  thoroughly  irrigated  with  warm  water. 
This  should  be  all  the  more  radically  carried  out  when  there 
has  been  distinct  evidence  of  extravasation  ;  or,  without  such 
evidence,  when  the  wound  in  the  bowel  has  been  sufficiently 
large  to  render  it  probable  that  some  leakage  has  taken  place. 

Case  LXIII. — Stab  wound  of  the  abdomen,  with  multiple  wounds  of  tJie 
intestine  :  laparotomy  :  suture.     Becovery. 

A  man  aged  18  was  stabbed  in  the  abdomen  with  the  large  blade  of  a 
penknife.  The  wound  was  a  little  below  and  to  the  right  of  the  umbilicus, 
and  was  about  half  an  inch  in  lengtli.  The  patient  seemed  comfort- 
able, made  no  complaint,  showed  no  signs  of  collapse,  and  the  wound 
seemed  to  have  been  limited  to  the  abdominal  parietes.     The  pulse,  how- 


(JUNSIIOT   AVOUNDS  319 

ever,  was  small  and  wiry,  so  that  it  was  considered  wise  to  explore  tlie 
wound.  An  ana'sthetic  was  administered,  when  it  was  found  that  the 
parietes  had  been  completely  perforated.  The  abdominal  cavity  was  then 
opened  and  fomid  to  contain  more  than  a  quart  of  free  blood.  An  ex- 
amination of  the  bowel  revealed  three  incised  wounds  of  the  small 
intestine,  each  about  a  third  of  an  mch  in  length.  Two  wounds  were 
also  found  in  the  omentum,  and  one  in  the  mesentery ;  that  in  the  latter 
appeared  to  have  been  the  source  of  the  haemorrhage.  The  wounds  were 
closed  by  a  single  row  of  silli  Lembert  sutures.  The  patient  made  an 
excellent  recovery.     (Stimson,  'Annals  of  Surgery,'  1894,  vol.  xix.  p.  89.) 


CHAPTER   XXXVIII 

INJURIES  {continued),     gun-  and  pistol-shot  wounds 

Wounds  of  this  kind  fall  more  within  the  domain  of  military 
than  civil  sm-geons,  but  they  are  sufficiently  frequent  in  the 
practice  of  the  latter  to  warrant,  if  not  a  detailed  description 
of  the  symptoms  and  lesions,  at  least  a  careful  consideration 
of  the  question  of  treatment.  In  civil  practice  the  wounds 
met  with  are  mostly  those  inflicted  with  revolvers  and  fowling 
pieces ;  in  the  former  case  the  weapon  is  used,  as  a  rule,  at 
close  quarters  and  with  homicidal  intent ;  while  in  the  latter 
the  wound  is  mostly  the  result  of  accident,  and  varies  in 
severity  according  to  the  range. 

Symptoms.— Quite  as  much  difficulty  exists  in  determining 
the  nature  of  a  pistol-  or  gunshot  wound  as  in  the  case  of  in- 
cised wounds.  Not  only  does  shock  form  a  most  variable  con- 
comitant, but  the  gravity  of  the  lesion  itself  may  bear  no  ratio 
to  the  more  strictly  local  signs.  In  the  majority  of  instances, 
however,  there  will  be  both  local  and  constitutional  evidences 
of  perforation ;  and  it  must  be  taken  as  exceptional  where 
one  or  two  signs  at  least  do  not  stand  out  prominently. 

Tremaine,^  as  the  result  of  a  somewhat  extensive  experi- 
ence in  wounds  of  this  class,  in  both  military  and  civil  practice, 
states  that  he  has  been  led  to  the  following  conclusions  :  '  That 
the  calibre  of  the  ball,  the  proximity  of  the  weapon,  and  the 
position  of  the  wounds  of  entrance  and  exit  have  an  important 
bearing.     That,  as  regards  general  symptoms,  the  existence 

'  riiiladdpliia  Medical  Neivs,  18SG,  vol.  xh'x.  p.  GOl. 


320  THE   INTESTINES 

of  prolonged  shock,  a  lowered  temperature,  a  feeble  pulse,  great 
restlessness,  marked  anxiety  of  countenance,  accompanied  by 
tympanites  and  great  pain,  taken  in  connection  with  the  ana- 
tomical location  of  the  wound,  afford  very  strong  evidence  of 
a  perforating  wound  "of  the  intestines.  That  the  escape  of 
blood  from  the  anus  rarely  happens  soon  after  the  injury,  and 
is  consequently  of  little  value  as  a  diagnostic  sign.' 

As  exceptional  instances,  where  either  the  severity  or  the 
mildness  of  the  symptoms  is  liable  to  mislead,  may  be 
mentioned  first  the  case,  already  quoted,  where  the  patient 
was  apparently  moribund  from  severe  shock,  although  there 
was  no  perforation  ;  and,  second,  a  case  reported  by  Gerster,^ 
where  there  were  several  perforations  but  no  serious  sym- 
ptoms. In  the  former  case  the  bullet  had  only  perforated  the 
clothes  in  which  it  was  found,  the  skin  being  quite  intact ; 
in  the  latter  it  had  perforated  the  small  intestine  in  two  places, 
and  the  large  in  one.  The  case  was  that  of  a  boy  who  when 
admitted  into  hospital  showed  no  signs  of  shock,  internal 
haemorrhage,  or  escape  of  feeces,  yet  when  the  abdomen  was 
opened  about  six  hours  afterwards,  the  above  wounds  in  the 
bowel  were  found  with  extravasation  of  faeces  into  the  abdo- 
minal cavity,  and  commencing  peritonitis. 

Nature  of  tlie  lesion. — It  may  be  roughly  said  that  the 
lesion  produced  by  shot  or  balls  of  different  calibre  vary  only 
in  the  size  of  the  aperture  ;  in  all  respects  it  is  a  lacerated 
wound,  with  a  certain  amount  of  destruction  of  tissue  along 
the  track  taken  by  the  projectile.  The  size  of  the  aperture, 
however,  creates  a  serious  difference  ;  for  while  a  small  one 
may  become  completely  occluded  by  the  contraction  of  the 
muscles  surrounding  the  channel,  a  large  one  will,  as  regards 
both  parietes  and  bowel,  admit  of  the  escape  of  faeces. 

In  the  recent  war  between  Japan  and  China,  the  Japanese 
were  provided  with  two  kinds  of  rifles,  one  of  which  fired  a 
bullet  encased  in  a  hard  jacket  composed  of  copper  and  nickel, 
in  diameter  0-315  inch,  in  weight  238  grains,  and  with  an 
initial  velocity  of  1,850  feet  per  second ;  and  the  other  a  bullet 
entirely  composed  of  lead,  0-45  inch  in  diameter,  420  grains 
in  weight,  and  having  a  velocity  not  much  more  than  half 

'  Annals  of  S^irgci-r/,  18i)4,  vol.  xix.  p.  91. 


GUNSHOT   WOUNDS 


321 


that  of  the  other.  Christie,'  in  a  letter  to  the  '  British  Medical 
Journal,'  contrasts  the  effects  produced  by  each  kind.  In  the 
former,  where  the  bullet  is  smaller  and  travels  at  greater  velo- 
city, the  soft  parts  of  the  body  are  cleanly  perforated,  there  is 
neither  contusion  nor  laceration  ;  while  the  opposite  conditions 
are  observed  in  wounds  produced  by  the  larger,  softer,  and 
less  rapidly  travelling  bullets. 

The  course  of  the  bullet  in  the  abdominal  wall  is  often 
difficult  to  trace.  It  may  have  completely  perforated  the 
parietes,  and  a  dark-stained  aperture  of  entrance  may  be  seen, 
but  the  passage  of  a  probe  along  the  track  may  be  quite  impos- 
sible. This  difficulty  may  arise  from  one  of  two  causes — either 
the  unequal  contraction  of  the  powerful  parietal  muscles  so 


Fig.  45. — Pistol-shot  Wound  of  Small  Intestine.     (Bull) 

alters  the  direct  continuity  of  the  canal  that  it  is  practically 
rendered  impermeable,  or,  from  a  want  of  knowledge  as  to  the 
course  taken  by  the  bullet,  the  surgeon  fails  to  strike  the 
track.  The  point  is  of  considerable  practical  importance  to 
remember,  because  the  failure  in  any  endeavour  to  pass  an 
instrument  along  the  track  of  the  ball  should  not  mislead  the 
surgeon  into  the  belief  that  no  perforation  has  taken  place. 
In  Gerster's  case,  above  quoted,  it  was  not  possible  to  pass 
a  probe  along  the  track  in  the  abdominal  wall,  and  yet,  as 
noted,  there  were  three  intestinal  perforations. 

To  what  extent  a  ball  may  be  deflected  by  the  soft  parts 
through  which  it  passes,  it  is  not  possible  to  say.  It  is  held 
by  many  that  such  deflection  does  take  place,  while,  on  the 

'  Brit.  Med.  Jonrn.  1895,  vol.  i.  p.  822. 


322  THE    INTESTINES 

other  hand,  McGraw,'  a<3  the  result  of  numerous  experiments 
on  dogs  and  sheep,  maintains  that  the  track  is  always  a  per- 
fectly straight  one.  However  this  may  be,  one  fact  appears 
certain,  that  the  coil  of  bowel  most  injured  is  that  lying  imme- 
diately behind  or  opposite  the  track  in  the  abdominal  parietes. 

As  a  means  of  diagnosing  the  existence  of  perforation  in 
the  bowel,  Senn  has  suggested  inflation  of  the  intestine 
with  hydrogen  gas.  The  escape  of  gas  through  the  wound 
after  opening  the  abdomen  necessarily  indicates  that  the  bowel 
has  been  perforated.  By  many,  however,  this  method  of 
diagnosis  is  considered,  if  not  impracticable,  at  least  fre- 
quently objectionable.  The  tension  of  the  bowel  tends  to 
open  an  aperture  which  nature  may  have  already  efficiently 
sealed ;  and  thus  where  the  abdominal  cavity  has  been  free 
from  septic  contamination,  the  escape  of  fascal  matter  through 
the  dilated  orifice  will  add  a  source  of  danger  which  otherwise 
would  not  have  existed.  On  the  other  hand,  it  can  be  argued 
that  the  escape  of  gas  renders  it  impossible  to  overlook  an 
aperture  which  without  such  a  method  of  diagnosis  might  not 
have  been  detected. 

Prognosis. — It  may  always  be  said  that  the  smaller  the 
projectile  the  more  favourable  will  be  the  prognosis  ;  hence  a 
wound  produced  by  pellets  will  be  comparatively  less  serious 
than  one  produced  by  a  pistol  ball.  A  charge  of  shot  fired  at 
close  quarters  will  produce  a  much  graver  injury  than  after 
the  charge  has  spread. 

In  cases  where  no  operation  is  performed,  by  far  the 
larger  number  end  fatally  from  acute  general  peritonitis. 
Such  cases  as  recover  for  a  short  time  or  completely,  do  so 
from  the  formation  of  adhesions.  These  may  serve  to  occlude 
the  lacerated  orifices  until  the  slough  separates  and  is  carried 
away  with  the  fa3ces,  or  they  may  form  the  boundaries  of  a 
localised  peritonitis  which  ends  in  the  production  of  an  abscess. 
In  the  latter  case  the  abscess  may  burst  into  the  bowel,  the 
most  favourable  course ;  or  externally,  with  the  possible  sequel 
of  a  faecal  fistula  ;  or  into  the  peritoneal  cavity,  with  the  fatal 
result  of  acute  suppurative  peritonitis. 

In  cases  which  have  been  operated  upon,  that  is  to  say, 
in  which  laparotomy  has  been  performed,  the  chance  of  a 

'  Trans.  Amer.  Surg.  Assoc.  1889,  vol.  vii.  p.  123. 


GUNSHOT   WOUNDS  323 

successful  result  much  depends  upon  the  time  which  has 
elapsed  between  the  receipt  of  the  injury  and  the  operation. 
If  performed  within  six  hours,  the  prospects  are  much  more 
favourable  than  at  any  time  after  that ;  for  in  cases  of  extra- 
vasation, peritonitis  will  have  commenced,  and  this  always 
adds  a  serious  factor  to  the  existing  lesion. 

Statistics  do  not  afford  any  very  safe  means  for  determin- 
ing the  value  of  operation ;  for,  as  seen,  so  much  depends 
upon  the  size  of  the  projectile,  the  range  at  which  it  was  fired, 
and  the  period  of  time  elapsing  before  operation.  Numerous 
cases  of  recovery  are  recorded  where  it  appears  certain  that 
but  for  the  operation  a  fatal  result  must  have  ensued. 

Scott  ^  records  a  case  of  four  perforations  in  the  ileum 
which  were  successfully  closed  by  the  Czerny-Lembert  suture, 
the  patient  making  a  good  recovery.  BalP  operated  with 
success  on  a  case  in  which  there  were  seven  perforations 
which  were  sutured ;  the  operation  was  seventeen  hours  after 
the  accident.  Stimson^  successfully  sutured  two  perforations 
in  the  sigmoid  flexure,  the  patient  making  an  uninterrupted 
recovery.  Miles  *  gives  twelve  cases  of  laparotomy  with  four 
recoveries  ;  of  these  latter,  one  had  16  wounds  of  the  small 
intestine,  one  14,  another  10,  and  the  remaining  one  3. 
Carmalt  was  successful  in  a  case  where  there  were  five  wounds 
of  the  intestine  and  mesentery  (see  Case  LXV.).  Eoberts -^ 
operated  in  a  case  four  hours  after  the  receipt  of  injury. 
There  existed  eight  perforations  in  the  bowel  and  three  in  the 
mesentery.  The  wounds  were  closed,  and  the  patient  made 
a  good  recovery.  Woolsey  "^  records  a  case  of  sixteen  perfora- 
tions of  the  intestines  produced  by  a  pistol  of  '32  or  -38 
calibre.  All  the  perforations  were  in  the  small  bowel,  most 
in  the  lower  ileum,  and,  with  the  exception  of  four,  were 
closed  with  a  continuous  Lembert  suture  of  fine  silk.  Four 
of  the  perforations  were  so  close  together  that  separate  suture 
would  have  resulted  in  stenosis ;  hence  three  inches  of  the 


'  Neio  York  Medical  Record,  1890,  vol.  xxxviii.  p.  516. 

2  New  York  Med.  Jonrn.  1885,  vol.  xli.  p.  185, 

^  Annals  of  Surgery,  1894,  vol.  xix.  p.  90. 

■*  Trans.  Amer.  Surg.  Assoc.  ]  893,  vol.  xi.  p.  349. 

*  Lancet,  1894,  vol.  ii.  p.  1160. 

^  Annals  of  Surgery,  1896,  vol.  xxiii.  p.  423. 

-i  2 


324  THE    INTESTINES 

bowel  was  excised,  and  the  divided  ends  united  by  a  Murphy's 
button.  There  was  some  extravasation  of  fgecal  matter  and 
commencing  peritonitis.  The  abdominal  cavity  was  flushed 
out  with  large  quantities  of  sterile  normal  saJt  solution.  The 
patient,  whose  age  was  23,  made  a  good  recovery,  which  the 
author  largely  attributed  to  the  fortunate  circumstance  that 
he  had  eaten  nothing  for  twenty-four  hours  previous  to  being 
shot.  Tiffany  '  succeeded,  by  suture,  in  a  case  where  there 
were  found  at  the  operation  eight  perforations  of  the  small 
intestine  and  four  wounds  of  the  mesentery. 

As  regards  the  ultimate  lodgment  of  the  bullet,  if  it  does 
not  pass  right  through  the  body,  as  it  rarely  does,  it  may  find 
a  final  resting  place  in  the  soft  parts  of  the  parietes  opposite 
the  seat  of  entrance  ;  or,  if  it  becomes  spent  before  completely 
traversing  the  abdominal  cavity,  it  may  simply  pass  into 
the  bowel  or  fall  into  some  dependent  part  of  the  peritoneal 
cavity. 

It  must  be  remembered  that  balls,  especially  the  larger 
ones,  are  liable  to  carry  into  their  track  particles  of  clothing 
which,  from  their  naturally  septic  character,  are  likely  to  pro- 
duce inflammation  independent  of  any  due  to  the  perforating 
lesion. 

Treatment. — No  class  of  cases  has  given  rise  to  more 
discussion  in  recent  years  regarding  the  question  of  treatment 
than  that  under  consideration,  and  the  points  at  issue  may  be 
briefly  summed  up  in  the  simple  question  of  whether  laparo- 
tomy should  or  should  not  be  performed,  or,  in  other  words, 
whether  the  patient  should  be  left  to  the  unaided  efforts  of 
nature  or  whether  the  surgeon  should  intervene. 

From  the  conflicting  opinions  held  some  few  years  ago,  it 
would  have  been  impossible  to  deduce  a  method  of  practice 
which  had  sufficient  weight  to  enforce  it  as  the  only  correct 
one  to  adopt.  If  we  go  far  enough  back  we  find  a  distinct 
feeling  in  favour  of  non-interference.  But  in  the  most 
recently  expressed  views  there  is  a  clear  and  decided  leaning 
towards  active  intervention.  The  success  which  has  attended 
operations  in  cases  where  death  was  otherwise  inevitable,  as 
well  as  the  now  incontestable  safety  of  carefully  and  properly 

'  Avierican  Journal  of  the  Medical  Sciences,  1896,  vol.  cxi.  p.  551.     . 


GUNSHOT   WOUNDS  326 

performed  laparotomy,  have  largely  tended  to  clear  the  way 
for  a  definite  line  of  treatment.  If  a  bowel  has  been  badly 
perforated,  operation  alone  can  save  life  ;  if  on  the  other  hand 
the  perforation  has  been  small  and  capable  of  natural  repair, 
a  carefully  performed  laparotomy  should  neither  hinder  the 
reparative  process  nor  cause  any  additional  danger. 

Assuming  therefore  that  laparotomy  is  a  perfectly  proper 
operation  to  employ,  are  there  any  special  indications  against 
its  adoption  in  any  particular  case  ? 

As  has  ah-eady  been  pointed  out,  the  diagnostic  value  of 
probing  a  wound  is  practically  small,  for  in  a  case  of  complete 
perforation  it  may  be  impossible  to  pass  a  director  along  the 
track  of  the  bullet. 

If,  then,  there  is  distinct  evidence  of  a  wound  of  entrance, 
that  may,  for  all  practical  purposes,  be  deemed  sufdcient 
reason  for  entering  upon  other  considerations  regarding  the 
question  of  laparotomy.  The  most  important  of  these  is  the 
size  of  the  ball.  If  known  to  be  large,  the  question  is  settled, 
and  the  sooner  the  operation  is  performed  the  better.  The 
only  reason  for  delay  is  shock,  which  must  first  be  allowed 
to  pass  off  somewhat  before  the  shock  associated  with  every 
operation  is  added.  An  endeavour,  however,  must  be  made 
to  operate  before  general  peritonitis  has  set  in.  Approxi- 
mately it  may  be  said  that  this  serious  complication  com- 
mences, as  a  rule,  within  the  first  six  hours. 

Wounds  produced  by  pellets  of  small  shot,  and  especially 
when  the  symptoms  at  the  outset  are  very  slight,  do  offer, 
at  the  first  sight,  considerable  temptation  to  delay  operative 
interference.  Experience,  however,  teaches  that  death  is  the 
most  common  result  in  these  cases,  and  hence  laparotomy 
should  not  be  delayed.  The  only  instances  where  there  would 
seem  to  be  reason  for  non-interference  are  those  cases,  seen 
for  the  first  time  some  twelve  to  twenty-four  hours  after  the 
accident,  in  which  the  patient  appears  free  from  any  serious 
symptoms.  Here  it  is  possible  that  nature  is  effecting  repair, 
and  that  no  extravasation  has  taken  place  into  the  peritoneal 
cavity.  To  operate  under  such  circumstances  would  only 
possibly  impede  or  deleteriously  interfere  with  the  reparative 
process. 

T]ie  02)e ration. — If  it  is  right  to  speak  of  more  care  in 


826  THE   INTESTINES 

performing  laparotomy  for  one  cause  than  for  another,  then 
Buch  additional  care  should  be  exercised  in  the  treatment  of 
shot  wounds  of  the  intestine  ;  for  this  reason,  that  it  is  always 
necessary  to  handle  and  examine  the  whole  length  of  the 
intestinal  canal.  Hence  every  precaution  as  regards  warmth 
and  cleanliness  must  be  adopted  to  protect  the  bowels  during 
the  necessary  exposure  and  manipulation  to  which  they  are 
subjected. 

A  median  incision  below  the  umbilicus  is  the  one  usually 
selected,  as  affording  a  better  opportunity  of  both  examining 
the  abdominal  contents  and  treating  the  wounds  found. 

As  in  the  case  of  incised  wounds,  the  escape  of  gas  or 
faeces  on  opening  the  abdomen  will  definitely  indicate  the 
existence  of  perforation. 

A  loop  of  bowel  is  picked  up,  and  one  end  carefully  traced 
until  a  perforation  is  met  with.  After  this  is  closed  the 
search  is  continued.  If  the  bowel  is  not  returned  into  the 
abdomen  as  the  examination  proceeds,  it  should  be  carefully 
protected  till  the  end  of  the  portion  under  investigation  is 
reached,  when  it  should  be  replaced  before  the  other  portion 
is  commenced. 

As  regards  the  treatment  of  the  bowel  lesion,  all  depends 
upon  the  nature  and  extent  of  the  injury.  The  simplest  and 
best  method,  when  it  can  be  done,  is  to  close  the  aperture  by 
a  few  Lembert  sutures  ;  the  pouting  mucous  membrane  should 
be  turned  in  and  the  opposing  serous  surfaces  united.  If 
any  portion  of  the  bowel  is  so  badly  damaged,  either  from  the 
size  of  a  single  aperture  or  the  proximity  of  several  wounds, 
so  that  simple  union  does  not  appear  possible,  removal  of  the 
part  will  be  necessary. 

The  condition  of  the  mesentery  should  be  carefully  noted 
as  the  examination  of  the  bowel  proceeds  ;  this  is  the  more 
necessary  when  there  is  evidence  of  considerable  hsemorrhage. 
No  doubtful  bleeding  point  or  lesion  in  the  mesentery  should 
be  left  unsecured. 

After  both  small  and  large  intestine  have  been  completely 
and  carefully  overhauled  and  all  lesions  treated,  the  abdominal 
cavity  must  be  freely  and  efficiently  irrigated,  with  the  in- 
sertion of  a  drainage  tube  if  considered  advisable. 


GUNSHOT   WOUNDS  327 

As  regards  after  treatment,  everything  must  be  carried 
out  on  the  general  principle  of  rest,  sufficiently  discussed  in 
detail  already  under  other  operations  upon  the  intestinal 
canal,     (See  page  216.) 

There  are  various  points — such  for  instance  as  the  shape 
of  a  ball,  whether  round  or  conical  &c. — which  have  a  bearing 
upon  the  nature  of  the  lesion  produced,  which  are  unnoticed 
here.  Upon  these  and  many  others,  works  on  military  surgery 
must  be  consulted.  The  reader,  however,  may  profitably 
refer  to  an  exhaustive  and  very  instructive  discussion  on  gun- 
shot wounds  in  civil  practice  which  took  place  before  the 
American  Surgical  Association.^  Points  are  touched  upon 
there  which  a  limited  space  has  prevented  from  introduction 
here. 

Case  LXIV. — Pistol-shot  wound  of  the  small  intestine  :  seven 
perforations  :  laparotomy  :  suture.     Hecovery. 

W.  M.,  aged  22  years,  admitted  into  hospital  with  a  pistol-shot  wound 
of  the  abdomen.  When  seen  half  an  hour  after  the  accident,  he  was  per- 
fectly conscious,  warm,  with  a  pulse  of  96,  of  good  volume ;  temperature 
97-8^  F. ;  respiration  18.  He  had  vomited  solid  food.  He  retched  fre- 
quently, complained  of  great  pain  all  over  the  abdomen,  and  had  tenesmus. 
The  abdomen  was  tender,  but  not  swollen  or  tympanitic.  The  wound 
of  entrance  was  situated  an  inch  and  a  half  below  the  navel,  and  an  inch 
and  a  half  to  the  left  of  the  median  line.  It  was  half  an  inch  in  diameter, 
with  blackened  edges.  The  bullet  could  not  be  detected  anywhere  beneath 
the  skin.  The  wound  was  not  probed.  Seventeen  hours  after  the  acci- 
dent laparotomy  was  performed.  On  opening  the  peritoneal  cavity,  bloody 
serum  without  any  faecal  masses,  but  containing  small  clots,  flowed  out 
freely.  Several  coils  of  intestine,  representing  three  or  four  feet  in  length, 
were  then  pulled  out  of  the  wound  and  carefully  examined.  The  intestine 
and  mesentery  were  coated  here  and  there  with  clots  and  flakes  of  fibrin. 
The  bowel,  as  it  was  withdrawn,  was  placed  under  layers  of  towels  and 
occasionally  drenched  with  warm  water.  The  first  wound  was  about 
half  an  inch  in  diameter,  situated  naidway  between  the  attached  and  the 
free  border  of  the  intestine  and  several  feet  from  the  caecum.  The  serous 
coat  was  clean  cut,  the  mucous  membrane  lacerated  and  everted.  Six 
other  wounds  were  found,  and  in  each  instance  the  everted  mucous  mem- 
brane acted  as  a  plug.  All  the  wounds  were  closed  with  Lembert  sutures. 
The  patient  made  a  good  recovery.  (Bull,  '  New  York  Med.  Journ.'  1885, 
vol.  xli.  p.  185.) 

'  See  Trans.  1889,  vol.  vii.  p.  123. 


328  THE   INTESTINES 

Case  LXV. — Bevolver-sJwt  wound  of  the  intestine  and  mesentery  : 
five  perforations  :  suture.     Recovery. 

The  patient  was  a  lad  between  12  and  13  years  of  age,  who  had 
accidentally  shot  himself,  at  about  11  a.m.,  with  a  •22-calibre  revolver 
held  in  immediate  proximity  to  the  abdomen.  When  seen,  there  was  no 
pain  in  his  abdomen,  and  the  only  soreness  he  would  acknowledge  was 
directly  at  the  point  of  entrance  of  the  bullet,  which  was  about  half  an 
inch  to  the  left  of  and  a  little  above  the  umbilicus.  The  wound  was 
about  a  quarter  of  an  inch  in  diameter,  with  discoloiired  edges  ;  and  his 
trousers  and  shirt  (the  only  garments  he  wore)  had  perforations  in  them 
corresponding  to  the  situation  of  the  wound. 

The  wound  was  explored  and  found  to  go  nearly  perpendicular  to,  but 
slightly  downward  and  outward,  and  evidently  entirely  through,  the 
abdominal  wall.  An  incision  was  carried  along  the  track  of  the  wound, 
and  continued  to  and  then  along  the  median  line.  No  blood  appeared 
in  the  abdominal  cavity,  and  at  first  no  evidences  of  injury  to  the  contained 
organs  ;  but  on  drawing  the  intestines  out,  protecting  them  at  the  same 
time  by  keeping  them  wrapped  in  moist,  warm  aseptic  towels,  and  passing 
them  gently  and  rapidly  through  the  fingers  in  search  for  an  injury,  a 
double  perforation  in  the  upper  part  of  the  small  intestine  was  revealed. 
These  perforations  were  evidently  the  points  of  entrance  and  exit  respec- 
tively of  the  buUet,  and  were  separated  by  about  half  an  inch  of  sound 
tissue.  These  were  sewed  up  as  one  wound,  using  very  fine  silk,  by  the 
Lembert  suture.  Continuing  the  search,  two  other  very  similar  vvounds 
were  found  in  the  large  intestine  which  were  treated  in  the  same  way,  and 
later  a  single  perforation  in  the  mesentery,  directly  at  its  junction  with 
the  intestine.  In  all,  five  separate  wounds  were  found.  No  escape  of  the 
contents  of  the  intestine  had  occurred,  and,  as  mentioned,  there  was  no 
haemorrhage  ;  but  the  bullet  and  two  small  pieces  of  cloth  were  found. 
The  intestines  were  replaced,  the  abdomen  thoroughly  flushed  out  with 
warm  boiled  water,  and  the  external  wound  closed  with  silkworm-gut 
sutures. 

He  had  eaten  nothing  that  morning.  He  had  drunk  some  milk  about 
an  hour  before  the  accident,  and  was  waiting  for  his  dinner.  This  ac- 
counted for  the  empty  condition  of  his  stomach  and  his  bowels  and  the 
absence  of  faecal  extravasation  through  the  intestinal  wounds.  The 
bowels  moved  in  the  course  of  the  first  week.  Five  months  after  the 
operation  he  was  in  perfect  health.  (Carmalt,  '  Annals  of  Surgery,'  1895, 
vol.  xxi.  p.  360.) 

CHAPTEK   XXXIX 

FOREIGN    BODIES 

It  would  involve  far  too  extended  a  discussion  of  the  sub- 
ject to  attempt  to  deal  with  all  the  foreign  bodies  which  may 
pass  into,  pass  through,  or  arise  within  the  intestinal  canal. 


FOREIGN   BODIES  329 

It  is  only  proposed  to  consider  certain  of  these,  and  more 
particularly  to  treat  of  the  troubles  to  which,  when  impacted, 
they  give  rise.  It  may,  imimmis,  be  broadly  pointed  out 
that  there  is  hardly  a  body,  which  is  able  to  pass  through  the 
oesophagus  into  the  stomach,  which  will  not  pass  unobstructed 
throughout  the  entire  length  of  the  intestinal  canal.  That 
a  certain  body  becomes  impacted  in  the  gut  is  rather  an  acci- 
dent than  dependent  upon  any  definite  and  constant  cause.  A 
body  similar  in  all  respects  to  one  which  has  become  obstructed 
and  led  to  a  fatal  issue  in  one  case,  has  in  another  passed 
harmlessly  through  the  entire  bowel.  The  weekly  medical 
periodicals  frequently  contain  the  record  of  a  patient  who 
has  successfully  passed  per  rectum  some  body  of  extraordinary 
shape,  size,  or  consistency.  They  are  all  of  interest  as 
showing  what  nature  can  do,  and  what  the  surgeon  may 
reasonably  hope  for  in  any  case  where  he  knows  that  a  certain 
object  has  been  swallowed.  What,  however,  we  have  prin- 
cipally to  deal  with  here,  is  the  mischief  a  body  may  set  up 
if  perchance  it  does  not  pass  unchecked  through  the  bowel ; 
and  what  therefore  the  surgeon  should  be  prepared  for,  if  his 
favourable  expectations  are  not  realised  ;  or  what  he  should 
be  in  a  position  to  recognise  if  no  clear  history  is  forthcoming 
to  indicate  the  true  cause  of  the  symptoms. 

It  is  proposed  to  embrace  in  the  consideration  of  the 
subject  both  the  small  and  the  large  intestine,  for  while  there 
may  be  some  slight  differences,  there  are  many  more  points 
of  agreement.  The  lesions  which  may  arise  as  the  result  of 
impaction  in  either  portion  of  the  bowel  are  much  the  same. 

Nature  of  foreign  bodies. — It  need  scarcely  be  pointed  out 
that  there  is  hardly  any  limit — except  regarding  size — in  shape, 
consistency,  and  weight  of  the  bodies  which  may  become  lodged 
in  some  part  of  the  bowel.  In  the  case  of  sane  people,  it  is 
frequently  some  article  of  diet,  such  for  instance  as  a  fish 
bone,  or  other  small  bone  either  whole  or  in  fragments, 
fruit  stones,  &c. ;  while  in  lunatics,  and  those  who  practise 
tricks  of  jugglery,  they  are  knives,  forks,  spoons,  tobacco 
pipes,  broken  pieces  of  china,  glass,  &c.  In  the  former  class 
of  patients  it  more  frequently  happens  that  nothing  is  knowB 
of  the  fact  that  something  has  been  swallowed  likely  to  account 
for  the   symptoms  which  subsequently  arise,  except  in  such 


330  THE   INTESTINES 

instances  as  the  accidental  swallowing  of  a  dental  plate,  a 
coin,  a  pin,  and  suchlike  articles.  In  the  latter  class,  how- 
ever, some  clue  usually  exists  from  the  absence  or  loss  of 
certain  articles  previously  known  to  have  existed,  and  the 
confession  on  the  part  of  the  individual. 

There  is  a  class  of  bodies  within  the  intestine  of  natural 
formation  which  are  sometimes  the  cause  of  serious  troubles — 
namely,  intestinal  concretions  or  enteroliths,  and  biliary 
calculi.     These  will  receive  separate  consideration  later. 

Course  of  a  foreign  body  in  process  of  natural  expulsion. — 
The  best  guide  to  the  symptoms  connected  with  the  lodgment 
or  impaction  of  a  foreign  body  is  a  knowledge  of  the  processes 
which  nature  adopts  for  its  expulsion. 

While  it  is  possible  for  the  body  to  lodge  and  produce  its 
ill  effects  in  any  part  of  the  canal,  from  the  duodenum  to  the 
sigmoid  flexure,  it  more  frequently  happens  in  the  neighbour- 
hood of  the  caecum.  Here  it  may  become  impacted  in  the 
narrowed  orifice  of  the  ileo-cascal  valve,  or  lodged  in  the  csecum. 
Science  has  recently  in  a  very  remarkable  way  demonstrated 
the  fact  that  foreign  bodies  do  become  lodged  at  these  sites, 
and  that  such  lodgment  is  capable  of  detection  during  life. 
Sidney  Eowland  ^  briefly  describes  a  case  where  by  means  of 
the  E5ntgen  X  rays  he  was  enabled  to  show  that  a  halfpenny 
which  a  child  of  6  years  of  age  had  swallowed  some  four 
months  previously,  and  which  had  given  rise  to  constant 
symptoms,  was  lodged  at  the  ileo-csecal  valve.  The  skiagraph 
showed  the  halfpenny  lying  on  the  right  iliac  bone. 

The  following  pathological  events  m.ay  occur  where  a 
foreign  body  becomes  lodged  at  any  particular  part : 

1.  It  causes  ulceration  of  the  bowel,  which, 

2.  Without  the  previous  formation  of  adhesions,  may  lead 
to  perforation  directly  into  the  peritoneal  cavity,  but  which, 

3.  With  adhesion,  may  lead  to  a  localised  abscess. 

4.  The  abscess  bursting  may  create  a  communication  with 
(a)  the  outside  of  the  body,  (b)  the  interior  of  some  neighbour- 
ing viscus,  or  (c)  the  general  peiitoneal  cavity. 

5.  It  may  cause  temporary  obstruction  or 

6.  Acute  intestinal  obstruction. 

'  Brit.  Med.  Journ.  1896,  vol.  i.  p.  807. 


F0REIC4X   BODIES  331 

7.  Certain  bodies  such  as  needles  may  pass  innocuously 
through  the  tissues. 

Symptoms. — With  so  many  possibilities  regarding  the  course 
which  a  foreign  body  may  pursue,  the  symptoms  -which  arise 
must  be  almost  as  numerous  and  distinctive.  In  most  cases 
the  course  which  each  takes  will  have  its  own  train  of  sym- 
ptoms, as  well  as  its  own  proper  line  of  treatment. 

1.  When  the  body  causes  ulceration. — "VATiether  or  not 
symptoms  manifest  themselves  in  connection  with  ulceration 
of  the  bowel  will  depend  mostly  upon  the  amount  of  ulcera- 
tion present.  Even  when  small  it  may  lead  to  enteritis,  but 
when  large  and  extending  around  the  entire  circumference  of 
the  bowel,  it  may  be  followed  by  stricture.  The  symptoms  in 
connection  with  these  conditions  will  be  chiefly  those  of  bowel 
irritation,  as  shown  by  diarrhoea,  pains  mostly  of  a  colicky 
character,  and  other  disorders  connected  with  deranged  intes- 
tinal action.  As  stricture  advances  and  the  canal  becomes 
narrow,  symptoms  of  obstruction  may  set  in  either  gradually 
or  more  or  less  suddenly. 

2.  Perforation  of  the  boivel  ivithout  adhesions. — In  all  cases 
where  previous  thinning  of  the  bowel  has  taken  place  by 
ulceration,  or  the  immediate  perforation  of  the  intestinal  wall 
has  been  of  larger  dimension  than  such  as  might  be  produced 
by  the  passage  of  a  needle,  the  immediate  result  of  the  ex- 
trusion of  the  body  into  the  general  peritoneal  cavity  is  to 
set  up  acute  peritonitis.  In  these  cases  it  not  infrequently 
happens  that  the  patient  is  enjoying  perfect  health,  with  no 
indication  of  any  bowel  trouble,  up  to  the  moment  perforation 
takes  place.  Then  follow  acute  pain,  collapse,  and  later  all 
the  symptoms  of  peritonitis,  from  which  the  patient  rapidly 
dies. 

A  very  good  example  of  such  a  sequel  to  the  ejection  of  a 
foreign  body  is  recorded  by  Nichols.  It  will  be  observed  that 
there  is  little  to  distinguish  the  symptoms  thus  arismg 
suddenly  from  such  a  cause,  from  those  connected  with  per- 
forations of  the  stomach  or  bowel  from  other  pathological 
lesions. 


332  ,  THE    INTESTINES 

Case  LXVI. — Perforation  of  the  bowel  by  a  crotvn  of  a  sj)ecies  of  spear 
grass  :  acute  peritonitis.     Death, 

Lance- Corporal  M.,  according  to  his  own  statement,  was  perfectly  well 
until  the  morning  of  February  14,  1894.  On  that  day,  at  8  a.m.,  while  at 
the  ration  stand,  he  suddenly  felt  ill,  with  great  pain  at  the  bottom  of  the 
belly.  After  completing  his  duty  and  lying  down  some  time  in  the 
barrack  room,  he  walked  to  hospital  about  a  quarter  of  a  mile,  where  he 
arrived  at  11  a.m.,  appearing  very  ill.  No  cause  could  be  discovered  for 
his  illness,  which  was  diagnosed  as  peritonitis,  and  ended  fatally  two 
days  afterwards.  At  the  post  mortem  the  intestines  were  covered  with 
lymph,  and  there  were  several  ounces  of  foul  acrid  matter  in  the  peritoneal 
cavity.  This  was  found  to  come  from  a  minute  hole  in  the  gut,  about  a 
yard  above  the  caecum.  The  hole  was  the  size  of  a  Nc.  5  shot.  One 
inch  from  it  was  seen  a  piece  of  grass  sticking  in  the  mucous  membrane. 
It  was  the  crown  of  a  species  of  spear  grass  common  in  that  part  of  the 
country.  It  had  penetrated  about  half  an  inch  between  the  mucous  and 
muscle  coats.  There  seemed  little  doubt  that  the  hole  which  gave  exit 
to  the  faeces  and  caused  the  acute  peritonitis  had  been  due  to  a  similar 
piece  which  escaped  observation.  (Nichols,  '  Brit.  Med.  Journ.'  1894, 
vol.  i.  p.  1242.) 

3.  Perforation  after  the  formation  of  adhesions. — In  any 
case  of  slowly  progressive  ulceration,  as  the  result  of  the  im- 
pacted body,  it  is  more  than  likely  that  some  inflammatory 
process  will  advance  beyond  the  actual  seat  of  ulceration ;  and 
as  soon  as  this  reaches  and  involves  the  peritoneal  surface, 
adhesions  usually  take  place  between  the  affected  part  and 
some  neighbouring  tissue  or  organ.  Any  escape  therefore 
of  the  body  into  the  general  peritoneal  cavity  is  for  the  time 
being  prevented.  The  body,  however,  gradually  finds  its  way 
out,  accompanied  possibly  with  some  of  the  septic  contents  of 
the  bowel.  It  forms  a  bed  for  itself  in  the  midst  of  the  newly 
formed  adhesions.  Up  to  this  stage  there  may  have  been  no 
symptoms  to  indicate  the  process  which  was  taking  place 
within  the  abdomen.  Any  further  advance,  however,  will 
soon  become  manifest.  One  direction  in  which  this  may 
take  place  is  in  the  formation  of  an  abscess,  which,  as  it 
increases  in  size,  may  finally  burst,  either  through  the  parietes 
externally,  internally  into  some  viscus,  or  into  the  general 
cavity  of  the  peritoneum.  The  vaiious  symptoms  therefore 
which  may  develop  will  depend  upon  which  of  these  courses 
is  taken. 

4.  77//'    abscess    hursts   (a)    externally. — That   the    abscess 


FOREIGN    JiOUTES  .333 

is  tending  towards  the  surface  of  the  body  soon  becomes 
manifest. 

The  first  symptom  will  be  the  feeling  of  a  tumour  in  the 
abdomen,  somewhat  tender  on  palpation.  As  the  parietes 
and  skin  get  involved,  the  evidence  of  inflammatory  mischief 
becomes  more  prominent,  until  it  is  sufficiently  clear  that 
an  abscess  exists.  With  the  exception  of  possibly  some  rise 
of  temperature,  these  conditions  may  progress,  especially  in 
the  earlier  stages,  with  little  or  no  constitutional  disturbance. 
If  the  abscess  is  not  opened  it  will  burst,  and  then,  if  the 
body  be  not  ejected,  either  continue  to  discharge  through  a 
fistulous  opening  or  leave  the  more  serious  condition  of  a 
fiecal  fistula.  The  latter  condition  depends  upon  the  size 
of  the  ulcerated  aperture  in  the  bowel  left  after  the  passage 
through  it  of  the  foreign  body.  If  on  the  other  hand  the  body  be 
removed  while  the  communication  with  the  bowel  has  already 
healed,  a  complete  subsidence  of  all  symptoms  should  follow. 

The  treatment  of  any  case  depends  upon  the  stage  to 
which  the  process  has  extended.  Any  attempt  of  the  surgeon 
to  deal  with  it  at  its  earliest  period,  when  little  more  than 
an  ill-defined  tender  tumour  can  be  felt  within  the  abdomen, 
must  be  undertaken  with  care.  Although  the  abscess  may 
be  localised  it  may  not  yet  have  contracted  adhesions  to 
the  parietes,  so  that  any  endeavour  to  open  it  necessarily 
involves  opening  at  the  same  time  the  general  peritoneal 
cavity.  If  an  exploratory  operation  is  decided  upon,  the 
treatment  of  the  abscess  when  opened  will  depend  upon 
whether  or  not  there  is  any  material  communication  with  the 
bowel.  If  there  be  no  bowel  communication,  then  after 
emptying  the  abscess  cavity  it  should  be  dried  and  dusted 
with  iodoform  or  stuffed  with  iodoform  gauze.  If  on  the 
other  hand  the  serious  complication  of  a  fsecal  fistula  exists, 
the  surgeon  will  have  to  choose  between  excision  of  the  part, 
or  attachment  of  the  bowel  to  the  parietes  and  the  estabhsh- 
ment  of  a  faecal  fistula  or  an  artificial  anus.  Whatever  the 
difficulty  encountered,  cleansing  of  the  peritoneal  cavity  must 
be  efficiently  carried  out. 

When  there  is  distinct  evidence  of  an  abscess  on  the 
abdominal  surface,  there  is  little  fear  that  adhesions  have  not 
formed  with  the  parietes,  and  no  danger  exists  therefore  of 


334  THE    INTESTINES 

opening  the  peritoneal  cavity.  An  incision  is  all  that  is 
needed,  and  if  perchance  a  fecal  fistula  remains,  it  can  be 
subsequently  dealt  with  by  an  intra-abdominal  operation, 
supposing  it  does  not  naturally  close. 

It  should  be  noted  that  the  result  of  adhesions  and  the 
embedding  of  a  foreign  body  within  them  does  not  necessarily 
lead  to  the  formation  of  an  abscess.  In  cases  where  foreign 
bodies  remain  for  any  length  of  time  within  the  body  cavity, 
it  is  by  such  a  process  of  adhesive  formation  that  they  are 
cut  off  and  kept  secure  for  variable  periods.  At  any  time, 
however,  inflpanmatory  mischief  may  be  set  up  and  the 
sequence  of  events  above  described  take  place. 

Case  LXVII. — Perforation  of  the  bowel  by  a  fish  bone  :  formation  of 
intra-abdominal  abscess  :  opened.     Recovei-ij. 

M,  D.,  aged  34  years,  was  admitted  into  the  Victoria  Infirmary, 
Glasgow,  on  June  1,  1894.  His  complaint  was  that  for  two  weeks 
previously  he  had  suffered  from  pain  in  the  right  inguinal  region.  On 
examination  of  the  abdomen  a  rounded  tumour  could  be  felt  in  the  right 
inguinal  region,  on  a  level  with  the  anterior  superior  spine  of  the  ilium, 
and  about  two  and  three-quarter  inches  to  the  right  of  the  middle  line. 
It  was  tender  on  pressure,  of  firm  consistence,  and  its  limits  could  be 
palpated.  The  skin  was  freely  movable  over  it.  The  patient  was  in  a 
medical  ward  for  five  weeks  before  transference  to  a  surgical  ward. 
During  that  period  his  temperature  had  fluctuated  between  97°  and 
99°  F.  His  bowels  had  never  troubled  him,  except  that  there  was  a 
slight  tendency  to  looseness.  The  tumour  had  increased  in  size,  until  on 
July  3,  the  morning  of  the  operation,  it  presented  a  well-marked  projec- 
tion of  the  parietes,  with  some  redness  of  the  skin,  excessive  tenderness, 
and  a  sense  of  fluctuation.  An  incision  was  made  over  the  swelling, 
when  pus  escaped ;  and  in  digital  examination  of  the  cavity,  a  fish  bone 
was  accidentally  discovered  lying  loose  within  it.  The  patient  made 
a  good  recovery.  (A.  Ernest  Maylard,  '  Trans.  Path,  and  Clin.  Soc, 
Glasgow,'  1895,  vol.  v.  p.  197.) 

(b)  The  abscess  hursts  into  some  viscus. — This  termination 
of  nature's  endeavour  to  get  rid  of  a  foreign  body  is  rare ;  and 
from  recorded  cases  it  would  seem  that  the  bladder  is  the 
viscus  most  frequently  perforated.  It  is  usually  not  until  the 
body  has  ulcerated  its  way  through,  or  an  abscess  has  burst 
with  ejection  of  the  body  into,  the  bladder  that  symptoms  of 
any  urgency  arise,  and  then  those  that  do  appear  are  solely 
connected  with  that  organ.  The  patient  soon  complains  of 
irritability  of  the  bladder ;  there  is  frequency  of  micturition 


FOREIGN   BODIES  335 

associated  with  pain.  The  urine  may  contain  particles  of 
fecal  material  and  pus,  and  when  passed  be  accompanied 
by  gas.  The  passage  of  a  sound  may  or  may  not  detect  the 
presence  of  the  body.  The  presence  of  gas  and  fecal  matter 
will  at  once  suggest  a  fistulous  communication  with  the  bowel, 
although  the  true  cause  of  the  connection  may  not  be  so  easy 
to  determine.  Bodies  which  pass  into  the  bladder  from  the 
bowel  may  be  naturally  expelled  per  urethram ;  failing  such 
a  result,  they  will  need  to  be  removed  either  by  perineal  or 
suprapubic  cystotomy.  In  cases  where  a  fistula  exists  between 
the  bowel  and  the  bladder,  it  may  be  considered  necessary  to 
perform  an  abdominal  operation  to  close  the  two  apertures. 
This,  however,  should  not  be  attempted  until  nature  has  been 
given  a  fair  trial  to  efl^ect  occlusion,  for,  as  will  be  seen  by 
the  case  below,  the  patient  made  a  complete  recovery  without 
operation. 

Case  LXVIII. — Passage  of  a  jportion  of  a  I'ahhif  s  femur  into  the  bladder  : 
expulsion  jper  urethram.     Hecovery. 

The  patient,  a  man,  when  first  seen  in  April  1882  was  suffering  from 
a  tumour  in  the  lower  part  of  the  abdomen.  Intestinal  irritation  had 
existed  for  some  months,  and  the  bladder  also  had  been  very  irritable. 
The  urine  contained  pus.  The  act  of  micturition  terminated  in  a  '  fizzing  ' 
sound,  from  the  escape  of  gas  along  with  the  larine.  No  stone  could  be 
detected  by  the  sound.  A  microscopical  examination  of  the  urine  re- 
vealed pus  and  various  kinds  of  bacteria.  In  June  the  patient  was  better, 
but  by  this  time  the  urine  was  discovered  to  contain  distinct  faecal  material. 
In  passing  his  urine  on  one  occasion,  he  thought  a  stone  had  come  away. 
On  examination  of  the  substance  it  proved  to  be  the  expanded  end  of  a 
rabbit's  femur.  After  this,  air  and  faeces  still  continued  to  pass,  but 
gradual  improvement  took  place,  and  finally  complete  recovery.  (Harrison, 
'  Medical  Press  and  Circular,'  1883,  vol.  ii.  p.  441.) 

Harrison  also  refers  to  two  other  cases.  In  one  a  hair- 
pin, and  in  the  other  a  slate  pencil  had  passed  from  the 
bowel  into  the  bladder.  In  both  instances  the  bodies  were 
removed  by  operation. 

(c)  The  abscess  bursts  into  the  peritoneal  cavity. — This  rarely 
happens  as  a  natural  result.  The  tendency  rather  is  for 
adhesions  to  form  with  other  parts  and  so  protect  the  perito- 
neal cavity.  The  cause  most  likely  to  bring  about  such  an 
untoward  result  is  some  undue  and  sudden  exertion  on  the 
part   of  the   patient,    who,  ignorant — from   the   absence   of 


336  THE    JNTESTINES 

previous  symptoms — of  any  internal  trouble,  is  suddenly 
seized  with  acute  abdominal  pain.  To  the  surgeon  nothing 
is  suggested  beyond  the  fact  that  possibly  perforation  has 
taken  place.  The  only  treatment  therefore  of  any  value  is 
exploratory  laparotomy.  The  discovery  of  a  foreign  body  or 
fsecal  material  within  the  abdominal  cavity  should  lead  to  a 
close  and  careful  search  for  any  perforation  in  the  bowel. 
The  further  treatment  of  the  case  will  depend  upon  the  state 
of  the  parts  found,  and  may  be  considered  sufficiently  dealt 
with  under  (b),  where  similar  conditions  exist. 

5.  Causes  temporary  obstruction. — A  foreign  body  may  be 
the  cause  of  temporary  obstruction,  arising  either  shortly  after 
it  has  entered  the  bowel  or  much  later,  when  it  has  caused 
ulceration  and  possibly  led  to  stricture. 

When  the  cause  remains  after  the  symptoms  have  sub- 
sided, there  is  a  likelihood  of  recurrence  at  some  future  date, 
with  the  possibility  that  the  subacute  or  temporary  attack 
may  at  any  time  become  acute  and  fatal.  This  latter  result 
is  most  liable  to  occur  where  stricture  is  the  cause  of  the 
obstruction.  In  such  cases  it  needs  but  an  effectual  plug  to 
completely  block  the  narrowed  aperture  to  produce  acute 
obstruction. 

The  symptoms  of  temporary  obstruction  are  mostly  those 
of  the  acute  form,  only  in  a  much  less  marked  degree.  The 
patient  may  vomit,  pass  neither  fasces  nor  flatus  per  rectum, 
although  suffering  from  constant  tenesmus.  There  will  be  a 
feeling  of  abdominal  discomfort  which  may  amount  to  pain. 
There  is  usually  an  absence  of  those  general  constitutional 
symptoms  which  present  such  a  marked  feature  in  the  acute 
form.  The  pulse  is  normal,  the  face  not  pinched  or  sunken, 
the  tongue  moist,  and  the  patient  not  painfully  distressed. 
The  attack  may  last  for  two  or  three  days,  when  flatus  begins 
to  pass,  faeces  follow,  and  all  the  symptoms  subside. 

In  treating  this  condition  the  patient  should  be  confined 
to  bed.  Purgatives  should  be  avoided,  but  small  doses  of 
belladonna  combined  with  a  little  opium  should  be  ad- 
ministered. The  rectum  and  lower  part  of  the  large  bowel 
should  be  emptied  by  the  use  of  large  fluid  enemata,  which 
may  be  repeated  some  three  or  four  times.  Nourishment 
should  be  limited  to  milk  and  easily  digested  soups  and  other 


FOREIGN    BODIES  ;«7 

tiuid  material.  The  stomach,  however,  will  probably  tolerate 
but  little,  and  should  not  therefore  be  burdened  with  too  much 
of  anything. 

Case  LXIX. — Temporary  intestinal  obstruction  from  ingestion 
of  a  quantity  of  gooseberry  slHns. 

Miss  B.,  agerl  55  years,  ate  a  quantity  of  gooseberry  skins,  the  resi- 
duum of  some  preserves  she  was  making.  On  the  following  day  she  was 
attacked  with  abdominal  pain,  which  increased  in  severity  and  was 
accompanied  by  vomiting.  There  was  complete  constipation,  with  pas- 
sage neither  of  faeces  nor  flatus.  Abdominal  distension  took  place,  and 
the  patient  complained  of  '  screwing  '  sensations  within  her  abdomen. 
Her  pulse  and  temperature  were  normal.  Tongue  moist.  Large  ene- 
mata  were  administered,  after  one  of  which  a  copious  motion  followed  ; 
for  some  days  subsequently  exceedingly  large  motions  were  passed.  All 
symptoms  subsided,  and  the  patient  rapidly  recovered.  (J.  Grant 
Andrew  and  A.  Ernest  Maylard,  Private  Case  Book.) 

6.  Causes  acute  intestinal  ohstruction. — A  fuller  description 
of  acute  obstruction  from  causes  of  this  character  will  be 
found  later  on,  but  it  may  be  briefly  alluded  to  here. 

The  causes  which  give  rise  to  temporary  obstruction  may 
equally  lead  to  the  acute,  fatal,  form,  A  good  illusti'ation  of 
acute  obstruction  is  afforded  by  a  case  published  by  Eve  ^ 
of  a  '  human  ostrich.'  A  man  in  order  to  gain  a  livelihood 
swallowed  '  penny  pieces,  halfpence,  pieces  of  tin,  paper,  cork, 
swivels,  watch  chains,  keys,  tin  tacks,  nails,  pieces  of  india- 
rubber,  sovereign  purses,  &c.'  He  was  suddenly  seized 
with  pain  in  the  abdomen,  in  the  region  of  the  umbilicus, 
from  which  time  symptoms  of  obstruction  set  in,  ending 
fatally  in  five  days.  At  the  post  mortem  the  lower  end  of 
the  ileum  was  found  completely  blocked  with  these  various 
objects. 

In  some  instances  it  may  be  possible  to  trace  the  symptoms 
to  their  true  cause  ;  more  frequently,  however,  a  considerable 
time  elapses  between  the  ingestion  of  the  body,  or  its  passage 
into  the  bowel,  and  the  onset  of  acute  symptoms.  Such  was 
the  sequence  of  events  in  the  above  case,  where  the  man 
considered  that  he  had  long  since  passed  per  rectum  all  the 
various  articles  which  he  had  swallowed.  In  cases  of  stricture 
resulting  from  ulceration  the  effect  of  an  impacted  foreign 

'   Brit.  Med.  Journ.  1894,  vol.  i.  p.  963. 


338  THE    INTESTINES 

body,  it  is  hardly  likely  that  the  true  cause  of  the  sudden 
obstruction  will  be  correctly  divined,  although  there  may 
previously  have  existed  symptoms  indicative  of  chronic  ob- 
struction.     (See  also  Obstruction  from  Gall  Stones.) 

7.  Effects  produced  hy  wandering  needles. — It  occasion- 
ally happens  that  needles  swallowed  find  their  way  through 
the  tissues  with  comparatively  slight  inconvenience  to  the 
patient.  It  would  appear  that  these  are  about  the  only 
foreign  bodies  which  having  passed  out  of  the  bowel  may 
become  encysted,  and  so  remain  for  indefinite  periods  em- 
bedded in  the  tissues.  Poel  relates  a  case  illustrative  of  both 
these  conditions.  The  patient,  as  will  be  seen  from  the  case 
narrated  below,  never  suffered  pain  except  when  a  needle 
began  to  perforate  the  abdominal  parietes,  but  after  its 
removal  all  sjanptoms  disappeared  until  another  presented 
itself.  After  death  from  another  cause,  needles  were  found 
encysted  in  the  deep  tissues. 

Case  LXX. — Wandering  and  encysted  needles. 

A  seamstress  was  admitted  into  hospital  suflferiog  from  acute  colicky 
pains  which  had  troubled  her  for  some  three  or  four  weeks.  The  pain 
was  referred  to  the  lower  part  of  the  abdomen  and  the  vagina,  and  in 
consequence  she  was  unable  to  assume  an  erect  position  or  walk  without 
greatly  increasing  the  discomfort.  Upon  examination  a  narrow  body 
about  two  inches  in  length  was  discovered  embedded  in  the  abdominal 
wall,  which  caused  great  pain  on  manipulation.  It  was  cut  down  upon, 
and  an  ordinary  sewing  needle  was  removed.  The  symptoms  then  sub- 
sided, except  that  slight  abdominal  pain  still  lingered.  A  second  needle 
was  removed  somewhat  later,  but  this  had  been  the  means  of  causing 
only  slight  discomfort.  She  was  admitted  into  hospital  about  a  year 
later  with  symptoms  the  result  apparently  of  fatty  liver,  from  which  the 
rejport  states  she  died.  At  the  post  mortem  six  needles  were  found  em- 
bedded in  the  omentum  at  one  place,  and  two  others  at  another.  Other 
needles,  either  singly  or  together,  were  found  practically  encysted,  as  no 
signs  of  inflammation  existed,  and  the  tissues  around  were  so  dense  that 
they  needed  to  be  torn  before  removal  could  be  effected. 

It  was  ascertained  that  three  years  before  her  admission  into  the 
hospital  two  needles  had  been  extracted,  one  after  an  incision,  and  one  by 
the  aid  of  the  fingers.  Similar  symptoms  were  present,  and  relief  followed 
upon  removal.     (Poel,  '  Medical  Record,'  188B,  vol.  xxiii.  p.  587.) 

Cases  of  peculiar  interest  are  occasionally  met  with. 
Thus  Dunlap  '   records  a  case   of  rapture  of  the  bowel  the 

'  New  York  Med.  Journ.  1803,  vo].  Ivii.  p.  IGG. 


TUBERCULAR   AND   TYPHOID    ULCEIIATION  331.! 

result  of  a  tapeworm,  which  he  beheved  had  become  en- 
tangled, and  m  the  efforts  made  to  free  itself,  had  so  eroded 
the  wall  as  to  cause  rupture.  Again,  cases  are  not  infrequently 
recorded  of  foreign  bodies  getting  into  a  herniated  loop  of 
bowel.  The  body  becomes  impacted,  and  changes  are  set  up 
which  lead  to  symptoms  suggestive  of  strangulated  hernia. 
Such  was  the  condition  in  a  case  narrated  by  Shiach,'  where 
a  triangular  piece  of  bone  got  lodged  in  a  femoral  hernia. 


CHAPTER   XL 

TUBERCULAR    AND    TYPHOID    ULCERATION 

The  small  intestine  may  be  affected  by  many  forms  of 
ulceration,  but  it  is  only  necessary  to  consider  here  two  kinds, 
tubercular  and  typhoid,  which  are  liable  to  give  rise  to  com- 
plications calling  for  surgical  intervention. 

Tubercular  ulceration. — This  form  of  ulceration,  so  fre- 
quently met  with  in  advanced  cases  of  pulmonary  phthisis, 
affects  mostly  the  lower  part  of  the  ileum,  although  any  portion 
of  the  canal  up  to  the  duodenum  may  be  involved.  The  tuber- 
cular process  attacks  almost  exclusively  Peyer's  patches  and  the 
solitary  glands.  At  an  early  stage  of  the  disease  the  glands 
contain  numerous  grey  granules  which  later  form  yellow  cheesy 
masses,  and  these  latter  breaking  down  give  rise  to  the  ulcer. 
The  tendency  is  for  the  process  to  extend  transversely  in  the 
direction  of  the  blood  vessels,  so  that  in  extreme  instances 
the  bowel  is  completely  encircled  by  ulceration.  Invasion 
may  also  take  place  in  a  longitudinal  direction,  producing 
therefore  ulcers  of  considerable  variety  in  size  and  shape. 

The  ulcer  in  its  most  typical  form  presents  an  excavated 
appearance,  with  thickened  overhanging  edges  and  an  ir- 
regularly tuberculated  floor  (see  fig.  46).  The  inflammatory 
thickening  which  precedes  the  process  of  ulceration  tends 
to  prevent  perforation,  although  in  exceptional  instances  this 
latter  result  ensues. 

While  ulceration  is  progressing  in  one  part  of  the  ulcer, 
cicatrisation  may  be  taking  place  in  another  ;  and  where  ni 

'  Brit.  Mccl.  Joiirn.  1893,  vol.  i.  p.  323.      , 


340 


THE   JEJUNUM   AND    ILEUM 


any  case  the  ulcer  has  extended  entirely  round  the  bowel,  the 
subsequent  healing  may  lead  to  stenosis  at  that  particular 
part.  Voehts  ^  records  a  case  where  two  strictures  were 
formed  ;  the  intestinal  convolutions  were  also  found  to  be 
injected  and  infiltrated  with  miliary  tubercles. 

Occasionally  adhesions  take  place  between  the  floor  of 
the  ulcer  and  neighbouring  parts.  In  one  case  which  came 
under  my  own  observation,  the  bowel  had  become  adherent 
to  the  parietes  on  the  left  side  of  the  umbilicus ;  a  chronic 
tubercular  abscess  formed,  and  pointed  beneath  the  skin. 
The  abscess  was  opened  and  scraped.  A  few  days  later  a 
faecal  fistula  unexpectedly  appeared.     The  patient  eventually 


Fig.  46. — Tuberculab  Ulcer  of  Intestine.     Naked-eye  Appeaeance.    (Coats) 
The  swollen  ovei hanging  edges  are  indicated 

died,  when  it  was  shown  at  the  post  mortem  that  the  tuber- 
cular process  was  one  which  had  extended  from  the  bowel 
outwards  through  the  parietes. 

Symptoms. — The  symptoms  connected  with  tubercular 
ulceration  of  the  bowels  are  in  many  instances  not  specially 
distinctive.  When  the  lower  part  of  the  ileum  is  markedly  in- 
volved there  may  be  tenderness  and  more  or  less  pain  in  the 
right  iliac  fossa.  The  bowels  may  move  freely,  amounting  in 
the  severer  forms  to  obstinate  and  uncontrollable  diarrhoea;  in 
other  cases  there  may  be  constipation.  When  the  bowel  sym- 
ptoms are  marked,  other  constitutional  disturbances  will  become 

'  Annals  of  Surgery,  1893,  vol.  xviii.  p.  579. 


TUBERCULAR   AND   TYPHOID   ULCERATION  341 

manifest,  such  as  emaciation,  hectic,  night  sweating,  and  those 
many  well-recognised  indications  of  advaricing  tuberculosis  in 
other  parts.  For  a  further  and  more  detailed  description  of 
these  conditions,  medical  works  should  be  consulted. 

Treatment. — From  a  surgical  point  of  view  it  is  only 
necessary  to  consider  the  possible  complications,  such  as 
perforation,  stricture,  and  localised  abscess.  So  far  as  these 
are  concerned,  they  are  all  too  rarely  met  with  to  admit  of 
any  statement  regarding  treatment  other  than  that  which  is 
included  under  general  surgical  principles.  If  other  circum- 
stances allowed,  perforation  might  be  reasonably  dealt  with  in 
the  same  way  as  in  the  case  of  perforations  occurring  from  other 
causes  ;  and  as  regards  stricture  some  form  of  plastic  operation 
may  be  required.  In  Voehts's  case,  already  alluded  to,  the 
strictures  were  successfully  excised.  An  abscess  arising  in 
connection  with  an  ulcer  should  be  opened  and  drained  with- 
out further  interference  in  the  way  of  scraping. 

Typhoid  ulceration. — Ulceration  of  the  bowel  in  typhoid 
fever  presents  some  features  of  marked  contrast  to  that  of 
tubercular  ulceration.  One  of  the  chief  points  of  distinction 
is  the  tendency  of  the  former  to  perforation,  and  in  this 
particular  feature  it  contributes  the  one  important  factor  of 
interest  to  the  surgeon. 

Inasmuch  as  the  process  of  ulceration  attacks  the  solitary 
and  agminated  follicles,  the  ulcers  are  found  wherever  these 
glands  normally  exist.  Thus,  then,  they  are  most  prominently 
present  in  the  lower  part  of  the  ileum.  The  ulcer  in  its  most 
typical  form  assumes  the  size  and  outline  of  the  follicle 
attacked ;  in  the  case  of  agminated  follicles  or  Peyer's 
patches,  it  is  oval  and  in  the  longitudinal  axis  of  the  bowel. 
It  contains  either  a  yellowish  slough  on  the  point  of  separa- 
tion, or  the  shreddy  remnants  of  one  which  has  become 
detached.  The  floor  of  the  ulcer  after  separation  of  the 
sloughs  is  thin  and  may  be  formed  of  the  muscular  coat,  or^ 
in  cases  where  the  ulcer  is  approaching  perforation,  nothing 
but  the  thin  serous  coat  may  intervene. 

The  result  of  ulceration  is  to  produce  either  a  localised 
abscess  or  general  peritonitis.  The  former,  from  its  excessive 
rarity,  may  be  passed  over,  although  the  possibility  of  its 
occurrence    should    l)e   borne    in    mind.       The  latter    is   not 


342  THE   JEJUNUM   AND   ILEUM 

infrequent,  and  almost  without  exception  fatal.  Cases  have 
been  reported  where  it  is  supposed  perforation  has  taken  place 
and  recovery  ensued.  There  is,  however,  the  great  difficulty 
of  deciding  with  any  degree  of  certainty  whether  in  these  cases 
of  recovery  perforation  did  actually  take  place.  And,  further, 
there  is  the  question  whether  the  supposed  perforation  might 
not  have  been  due  to  some  other  concurrent  disorder.  Thus 
the  case  recorded  by  McCall '  was  called  into  question  by 
Barr,^  who  considered  it  an  ordinary  case  of  appendicitis.  Re- 
membering, however,  that  both  the  csecum  and  the  appendix 
may  be  the  seat  of  typhoid  ulceration  and  perforation  ;  and 
that  in  this  particular  instance  the  patient  had  been  nursing 
her  son  who  was  recovering  from  an  attack  of  typhoid,  and 
that  her  own  sjmptoms  as  narrated  were  quite  typically 
those  of  the  disease,  there  is  considerable  weight  on  the  side 
of  believing  that  the  case  was,  as  reported,  one  of  recovery 
after  perforation. 

Other  cases  of  supposed  recovery  after  perforation  are 
reported.  Thus  De  Souza  Martins  ^  records  three  cases  and 
Branson ''  one.  The  trea.tment  in  Martius's  cases  consisted 
of  morphine  internally,  ice  to  the  abdomen,  and  iced  milk 
and  champagne  to  drink  ;  while  in  Branson's,  opium  was 
given.  Simon  ^  records  a  case  in  which  the  occurrence  of 
perforation  was  indicated  by  a  great  drop  in  the  temperature, 
by  collapse,  and  the  rapid  distension  of  the  abdomen,  even 
the  liver  dulness  being  lost.  Large  doses  of  opium  were 
given  and  recovery  followed.  The  conviction  that  perfora- 
tion had  taken  place  was  shared  by  two  other  medical 
attendants. 

Hawkins  ^  has  contributed  some  valuable  statistics  with 
regard  to  the  frequency  of  perforation,  the  period  of  occur- 
rence, and  the  seat  of  perforation. 

Frequency  of  'perforation. — In  the  case  of  children  from 
2  years  to  15  inclusive,  out  of  twenty  which  were  fatal  in  a 
total  of  251  cases  of  typhoid,  six  owed  their  death  to  perfora- 
tion.    In  adults  a  similar  number  of  investigations  showed  a 

•  Brit.  Med.  Journ.  1893,  vol.  ii.  p.  62.  ^  Ibid.  p.  207. 

'  Annual  of  the  Universal  Medical  Sciences,  1890,  vol.  i.  H — 33. 

'   Lancet,  1889,  vol.  ii.  p.  889. 

=■  B        Med.  Journ.  1896,  vol.  i.  p.  711.  «  Lancet,  1893,  vol.  ii.  p.  245. 


PLATE    XV. 


Fig.  47.— Typhoid  Ulceration  and  Perforation.— The  upper  specimen  has  a 
piece  of  whalebone  passing  through  a  perforation  in  the  centre  of  a  slough, 
which  had  caused  peritonitis.     (IV.I.M.,  Glas.) 


TYPlIOIi)    UI>CEIJATION  .14.'? 

mortality  of  forty-three,  out  of  which  eighteen  died  from 
perforation . 

Period  of  occurrence. — In  children  perforation  occurred 
during  the  third  week  in  one  case,  during  the  fourth  week  in 
two  cases,  during  the  ninth  week  in  one  case,  and  during  a 
rehipse  in  two  cases. 

In  adults  the  perforation  occurred  during  the  second  week 
in  two  cases,  during  the  third  week  in  six  cases  (at  the  early 
part  in  three  cases,  in  the  middle  in  one,  and  at  the  end  in 
two  cases\  at  the  end  of  the  fourth  week  in  two  instances, 
during  the  sixth  week  in  one  case,  during  the  seventh  week 
in  two  cases,  and  during  the  eighth  in  one.  The  dates  in  the 
remaining  four  cases  are  not  given. 

Seat  of  perforation.— k^  the  result  of  an  investigation  of 
seventy-two  necropsies  where  perforation  had  caused  death, 
Hawkins  found  that  in  sixty-one  instances  the  ileum  was  per- 
forated at  distances  above  the  ileo-csecal  valve  varying  from 
one  inch  to  six  feet,  being  in  the  majority  of  instances  six, 
twelve,  and  twenty -four  inches.  In  the  remaining  eleven  cases 
the  perforation  was  situated  as  follows :  the  colon  in  five 
instances,  the  anterior  surface  of  the  caecum  in  three,  and  the 
cffical  appendix  in  three.  Of  the  five  perforations  in  the  colon 
one  was  in  the  ascending  colon,  an  inch  above  the  csecum  (there 
being  also  a  perforation  in  the  ileum),  another  in  the  trans- 
verse colon,  and  three  in  the  descending  colon,  two  being  in 
the  upper  part  and  one  in  the  sigmoid  flexure. 

In  no  case  was  a  perforation  found  in  the  duodenum  or 
the  jejunum. 

There  are  facts  in  these  statistics  of  considerable  practical 
value  to  the  surgeon.  In  the  first  place,  it  will  be  noted  that 
by  far  the  largest  number  of  perforations  take  place  within  the 
first  twenty-four  inches  of  the  cgecal  extremity  of  the  ileum  ;  in 
the  second,  that  the  jejunum  is  almost  always  exempt  from 
perforation.  Again,  in  the  seventy-two  cases  where  death 
occurred  from  perforation,  in  only  one  instance  is  it  noted  that 
a  second  perforation  existed.  The  value  of  these  facts  con- 
sidered in  regard  to  operation  will  be  alluded  to  later. 

Symptoms. — In  all  but  exceptional  cases  perforation  takes 
place  during  the  obvious  progress  of  the  disease.  The  excep- 
tional instances  are  those  where  the  patient,  though  feeling 


344  THE   JEJUNUM   AND    ILEUM 

possibly  unwell,  is  continuing  bis  customary  avocation  when 
suddenly  be  is  seized  with  acute  symptoms. 

The  symptoms  connected  with  perforation  appear  to  be 
more  manifestly  acute  when  the  patient  is  not  suffering 
markedly  in  other  respects  from  the  effects  of  the  fever  poison. 
Thus  a  patient  who  has  only  a  mild  attack  of  typhoid,  or  who 
is  making  apparently  good  progress  towards  recovery,  becomes 
attacked  with  intense  abdominal  pain,  collapse,  vomiting, 
tenderness  over  the  abdomen  with  distension,  and  other 
symptoms  indicative  of  progressing  general  peritonitis.  On 
the  other  hand,  a  patient  who  is  already  seriously  ill  from  the 
disease  will  present  much  slighter  indications  ;  the  sudden 
onset  of  a  change  however,  marked  it  may  be  by  signs  of 
collapse,  with  a  fall  in  temperature,  increased  rapidity  and 
feebleness  of  pulse,  rapid  thoracic  respiration,  and  distension 
of  the  abdomen,  should  be  looked  upon  as  indicative  of  per- 
foration. '  The  sudden  appearance  in  the  course  of  enteric 
fever  of  symptoms  of  intense  collapse  even  when  no  distinct 
evidence  of  abdominal  inflammation  is  present,  points  to  the 
occurrence  of  perforation'  (Bristowe). 

Treatment. — The  introduction  of  the  question  of  operative 
intervention  in  the  treatment  of  perforation  is  of  comparatively 
recent  date.  According  to  Louis,'  who  has  carefully  investi- 
gated the  subject,  Leyden  in  May  1884  was  the  first  to  suggest 
treatment  by  laparotomy,  while  Mikulicz,  who  read  a  paper 
upon  the  subject  in  September  of  the  same  year,  appears  to 
have  been  the  first  to  act  upon  the  suggestion.  The  perfora- 
tion was  sutured  and  the  patient  recovered.  In  October 
of  the  following  year  (1885)  Liicke  operated  upon  a  woman 
aged  28  years.  Death  ensued  eleven  hours  after.  Since  these 
earlier  operations  several  others  have  been  performed,  and 
according  to  some  statistics  published  by  White  ^in  1892,  there 
had  been  nineteen  recorded  cases  of  laparotomy  for  perfora- 
tion from  typhoid  ulcer,  with  four  recoveries.  More  recently 
Senn  •*  has  recorded  three  cases  with  one  recovery.  In  this 
instance  the  patient  was  a  boy  aged  15  years,  who  had  been 
ill  for  five  weeks.     No  perforation  could  be  found,  but  a  large 

'  Le  Progres  Medical,  1890,  vol.  xii.  p.  512. 

'^  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  iii.  C — 101. 

■'  Ibid.  189H,  vol.  iii.  C  -77. 


TYPHOID   ULCERATION  34o 

quantity  of  fecal  matter  was  washed  out  of  the  abdominal 
cavity.  Senn  believed  that  the  perforation  had  become  closed 
by  adhesions.  Abbe  '  also  records  a  case  of  recovery  after 
operation.  The  patient  was  a  woman  aged  21  years,  and 
symptoms  of  perforation  developed  at  the  end  of  three  weeks 
of  the  fever,  when  convalescence  had  commenced.  (See  case 
below.) 

The  conditions  of  the  patients  in  whom  perforations  take 
place  vary  so  widely  that  the  prospects  of  a  successful 
operation  in  any  particular  case  can  only  be  properly 
reckoned  by  carefully  taking  them  into  account.  Thus,  to 
open  the  abdomen  when  perforation  has  occurred  in  a  patient 
who  is  in  the  height  of  the  disease  and  in  a  low  typhoid 
condition  can  hardly  be  considered  comparable,  as  regards 
the  j)rospects  of  success,  to  one  in  whom  convalescence  has 
reached  an  advanced  stage,  and  the  patient  therefore  in  a 
much  more  fit  condition  to  stand  the  additional  strain  of 
an  operation.  In  three  of  the  successful  cases  (van  Hook, 
Senn,  Abbe)  the  patients  do  not  appear  to  have  been  suffering 
deeply  from  the  disease  at  the  time  of  the  operation.  In  one, 
perforation  was  daring  a  relapse  after  convalescence  had  set 
in  ;  in  the  second  it  was  five  weeks  after  the  onset  of  the  ill- 
ness ;  and  in  the  third  it  was  three  weeks,  convalescence  having 
set  in. 

The  question  of  paramount  importance  to  the  surgeon 
when  brought  face  to  face  with  a  case  of  perforation  at  any 
stage  of  the  disease,  is  whether  laparotomy  should  be  per- 
formed. Louis,  who  reports  eleven  cases  of  operation, 
concludes  that  '  in  no  case  could  the  operation  be  said  to  have 
increased  the  danger  for  the  patient.'  He  therefore,  like  van 
Hook,  considers  that  laparotomy  is  only  contra-indicated  when 
the  patient  is  in  a  moribund  condition.  The  latter  author 
adds,  *  the  stage  of  the  fever  is  not  to  be  considered  as  an 
indication  or  as  a  contra-indication  for  laparotomy.'  Mears,''^ 
at  a  meeting  of  the  American  Surgical  Association  in  1888, 
advocated  operation  only  during  the  stage  of  convalescence,  at 
the  end  of  the  third  or  fourth  week.  It  will  thus  be  seen  that 
with  some  of  those  who  have  had  most  experience  in  dealmg 

'  Annals  of  Surgery,  1895,  vol.  xxi.  p.  362. 

-  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  iii.  B— 42. 


346  THE   JEJUNUM    AND   ILEUM 

with  this  fatal  complication  of  typhoid,  no  unanimity  of  opinion 
exists.  The  sm'geon  therefore,  so  far  as  our  knowledge  goes  at 
present,  must  decide  the  question  for  himself.  He  needs  to 
take  into  consideration  the  condition  of  the  patient  as  regards 
the  disease,  and  the  amount  of  physical  strength  he  possesses  ; 
and  the  means  at  his  disposal  for  rapidly  and  efficiently 
carrying  out  the  operation.  While  it  is  right  to  say  in  a 
general  way  that  operation  holds  out  the  only  hope,  still  there 
will  be  cases  where  such  hope  cannot  reasonably  be  enter- 
tained, and  the  patient  should  not  therefore  be  subjected  to 
useless  interference. 

Operation. — Every  means  must  be  .  taken  to  operate  with 
the  greatest  possible  rapidity,  and  with  a  care  which  shall 
ensure  the  efficient  closure  of  the  perforation  and  the  perfect 
cleansing  of  the  peritoneal  cavity. 

The  abdomen  should  be  opened  by  a  median  incision  below 
the  umbilicus.  The  hand  is  then  inserted,  and  the  ileum  at 
its  junction  with  the  caecum  sought  for  in  the  right  iliac  fossa. 
The  ileum  is  examined  by  tracing  it  upwards  or  away  from 
the  caecum.  As  soon  as  a  perforation  is  met  with,  it  should 
be  brought  sufficiently  into  view  to  enable  sutures  to  be 
passed. 

The  perforation  and  the  ulcer,  of  which  it  is  a  part,  should 
be  folded  in,  and  the  serous  surfaces  united  over  the  ulcer  by 
a  series  of  Lembert  sutures.  The  rarity  of  a  second  perfora- 
tion renders  it  unnecessary  to  subject  the  patient  to  the 
prolonged  exposure  and  manipulation  necessary  to  examine 
the  whole  length  of  the  intestinal  canal.  Such  examination, 
however,  must  be  carried  out  when  failure  to  find  the  perfora- 
tion in  the  more  common  seat  of  the  iliac  fossa  happens. 

After  returning  the  sutured  bowel  the  abdominal  cavity 
must  be  carefully  cleansed,  either  by  irrigation  with  warm 
boiled  water  or  by  simply  wiping  out.  If  deemed  advisable 
the  neighbourhood  of  the  intestinal  wound  should  be  stuffed 
with  iodoform  gauze.  The  pelvis  must  be  carefully  looked 
to,  as  also  Douglas's  pouch  in  females.  A  drainage  tube  may 
be  used  and  conducted  well  down  into  the  pelvis.  The  parietal 
wound  is  finally  closed  with  the  exception  of  the  aperture 
left  for  the  tube  when  the  latter  is  used,  or  for  the  gauze 
stuffing  when  the  deep  parts  are  packed. 


TYPHOID    ULCERATION  .347 

As  modifications  of  this  method  of  operating,  Liicke's 
suggestion  of  making  an  artificial  anus,  by  stitching  the  bowel 
at  the  seat  of  perforation  to  the  parietal  wound,  may  be 
carried  out ;  and  in  female  cases  Douglas's  pouch  can  be 
efficiently  drained  by  a  tube  passed  into  it  from  the  vagina. 
In  Abbe's  case  no  attempt  was  made  to  close  the  wound,  a 
large  abdominal  tamponnade  of  iodoform  gauze  was  placed 
within  the  abdomen  and  pelvis. 

There  is  probably  a  preference  for  an  artificial  anus  over 
immediate  suture  of  the  bowel  in  cases  operated  upon  at  an 
early  stage  of  the  disease.  The  free  escape  of  gas  and  faeces 
which  the  artificial  anus  admits  of,  Mears  considers  as  likely 
to  secure  the  most  perfect  rest  to  the  bowel,  and  lessen  thereby 
the  possibility  of  another  perforation.  Should  the  patient 
recover,  the  artificial  anus  can  be  successfully  dealt  with  by 
an  operation  at  some  subsequent  period. 

Case  LXXI. — Perforation  of  typJioid  ulcer  :  laparotomy  :  suture  of 
the  perforation.     Recovery. 

The  patient  had  a  sHght  attack  of  fever,  lasting  about  three  weeks. 
During  convalescence  a  relapse  occurred.  On  the  seventh  day  of  the 
supposed  relapse  an  enema  of  warm  water  was  given  for  the  purpose  of 
making  the  bowels  move.  This  was  followed  by  several  passages,  and  by 
violent  pain  in  the  ileo-csecal  region,  accompanied  by  profuse  diaphoresis, 
coldness  of  the  extremities,  and  an  excessively  pinched  and  anxious 
expression  of  the  countenance.  Temperature  105°  F. ;  pulse  126.  The 
pain  ceased  in  a  short  time.  In  a  few  hours  the  temperature  ran  up  to 
106°  F.,  the  pulse  to  132,  and  the  patient  suffered  from  tympanites  and 
tenderness  on  pressure  over  the  ileo-csecal  region.  The  abdomen  was 
opened  as  soon  as  possible,  and  more  than  a  pint  of  fluid  faeces  and  exudate 
mixed  with  flocculent  lymph  was  removed.  On  exposing  the  small  intes- 
tine numerous  ulcers  were  seen ;  all  the  coils  of  the  intestine  were 
congested  and  dull-looking ;  and  tlie  faecal  matter  was  freely  circulating 
in  the  peritoneal  sac.  A  perfectly  circular  minute  opening  was  found. 
This  was  closed  by  means  of  the  Lembert  sutiure,  three  rows  being  ap- 
plied on  account  of  the  brittle  condition  of  the  gut  wall.  The  peritoneal 
cavity  was  thoroughly  cleansed  out  with  hot  sterilised  water.  The  omen- 
tum was  drawn  over  the  injured  coil  of  intestine  and  sutured  to  the 
mesentery.  Douglas's  cul-de-sac  was  drained,  and  the  remainder  of  the 
abdominal  wound  was  closed.  Great  distension  followed  the  operation. 
This  yielded  to  enemata  of  sulphate  of  magnesium  with  glycerine  and 
water.  The  patient  recovered.  (Van  Hook,  '  Annual  of  the  Universal 
Medical  Sciences,'  1892,  vol.  iii.  C— 100.) 


348  THE   JEJUNUM   AND    ILEUM 

Case  LXXII. — Perforation  of  tyjyhoid  ulcer  :  laparotomy  :  suture  of 
the  perforation.  Recovery. 
The  patient,  a  woman,  21  years  of  age,  at  the  end  of  three  weeks  of 
typhoid  fever,  convalescence  having  begun,  developed  symptoms  of  per- 
foration of  the  bowel.  For  two  days  she  was  treated  by  poultices  and 
opium,  when  Dr.  Abbe  saw  her.  Her  abdomen  was  then  greatly  dis- 
tended ;  pulse  140  ;  temperature  104°  F. ;  lower  part  of  the  hypogastrium 
dull.  A  median  incision  below  the  navel  exposed  distended  coils  of 
deeply  congested  and  greatly  inflamed  intestine  smeared  with  sticky 
lymph.  The  pelvis  and  lower  abdomen  were  filled  with  a  collection  of 
foul,  purulent  and  fetid  intestinal  extravasation,  feebly  confined  by 
matted  coils  of  intestines  loosely  glued  together,  that  broke  apart  on  being 
touched,  but  which,  being  recognised,  enabled  him  to  introduce  clean 
sponges  under  the  upper  abdominal  wall.  Two  pints  of  foul,  purulent 
fluid  and  thick  lymph  were  cleaned  out,  and  the  abdomen  irrigated  with 
warm  sublimate  solution  (1  to  20,000),  followed  by  plain  warm  water 
irrigation.  On  the  lower  part  of  the  ileum  were  then  seen  many  thick 
oval  patches,  in  one  of  which  was  a  gangrenous  perforation  a  quarter  of 
an  inch  in  diameter,  from  which  intestinal  contents  were  seen  to  punap 
out.  This  was  closed  by  interrupted  silk  suture,  over  which  two  layers 
of  mattress  stitches  were  placed.  A  large  abdominal  tamponnade  of 
iodoform  gauze  was  placed  within  the  abdomen  and  pelvis,  and  no 
attempt  made  to  close  the  wound.  An  enema  of  hot  black  coffee  and 
whisky  was  given,  and  the  patient  put  back  to  bed  three-quarters  of  an 
hour  from  the  beginning  of  the  etherisation.  At  the  end  of  forty-eight 
hoiirs  she  was  in  good  condition,  except  for  tympanites.  The  tampon 
was  changed  and  five  grains  of  calomel  given.  A  little  fluid  faeces  leaked 
from  the  wound  after  the  calomel  acted  ;  this  continued  for  two  weeks 
and  then  it  ceased.  The  abdominal  wall  closed  in  rapidly  by  granula- 
tions, forming  finally  a  narrow  and  firm  scar;  The  convalescence  was 
rapid.     (Abbe,  '  Annals  of  Siu-gery,'  1895,  vol.  xxi.  p.  362.) 

Considerable  interest  attaches  to  this  latter  case  of  Abbe's, 
in  addition  to  that  connected  with  the  successful  treatment  of 
the  perforation.  The  operation,  it  will  be  observed,  was  not 
performed  until  two  days  had  elapsed  from  the  time  at  which 
perforation  took  place,  and  then  extensive  general  purulent 
peritonitis  with  copious  fsecal  extravasation  was  found  to  be 
present.  It  lends  encouragement,  where  one  is  too  frequently 
apt  to  lose  heart,  to  deal  most  thoroughly  and  carefully  with 
every  case  of  general  peritonitis  arising  from  whatever  cause, 
when  the  condition  is  met  with  in  the  ordinary  course  of 
operation. 


OBSTRUCTION  3-19 


CHAPTER   XLI 

OBSTRUCTION 

1.  INTERNAL    HERNIA 

(a)  INTO    NORMAL    PERITONEAL    FOSSAE 

(b)  through    ADVENTITIOUS    OR    CONGENITAL    APERTURES 
(C)    UNDER    BANDS,    CORDS,    DIVERTICULA,  &C. 

2.  ADHESIONS,  KINKING 

3.  INTUSSUSCEPTION 

4.  VOLVULUS 

5.  STRICTURE 

6.  GALL    STONES,    INTESTINAL    CONCRETIONS 

7.  TUMOURS    OF    THE    BOWEL    WALL 

8.  PRESSURE    FROM    WITHOUT 

9.  PERITONITIS,    ENTERITIS 

10.    CONGENITAL    ABNORMALITIES,    MiiLDEVELOPMENT 

While  it  is  usual  in  most  textbooks  to  treat,  under  the 
head  of  Intestinal  Obstruction,  the  large  as  well  as  the  small 
intestine,  I  have  preferred  to  keep  to  the  original  scheme  I 
had  in  view  of  dealing  as  far  as  possible  with  certain  regions, 
only  combining  portions  where  the  affections  involving  them 
are  practically  inseparable. 

The  part  played  by  the  jejunum  and  ileum  in  intestinal 
obstruction  comprises  considerably  more  than  that  of  any 
other  portion  of  the  alimentary  tract.  The  greater  length  of 
this  section  of  the  canal,  its  greater  mobility  and  more  exposed 
position,  naturally  predispose  it  to  sources  of  obstruction  not 
met  with  in  other  parts. 

Obstruction  of  either  the  jejunum  or  the  ileum  may  be 
brought  about  by  causes  external  or  internal  to  the  canal,  but 
not  organically  connected  with  it,  and  by  changes  involving 
the  bowel  wall  itself.  Eemembering  this  and  the  fact  that 
this  section  of  the  alimentary  canal  consists  of  a  long  tube, 
freely  movable,  with  soft  and  easily  compressible  walls,  it 
requires  very  little  effort  to  conjure  up  in  the  mind  the  various 
conditions  which  might  prove  the  direct  source  of  obstruction. 
Thus  the  tube  may  become  blocked,  bent,  twisted,  compressed, 


350  THE   JEJUNUM   AND    ILEUM 

kinked,  and  so  on.  But  such  conditions  need  to  be  technically 
expressed,  and  their  enumeration,  as  expressed  in  the  heading 
of  the  chapter,  forms  the  basis  for  their  consideration. 

1.  Internal  hernia  (A)  into  normal  peritoneal  fossae. — 
Anatomically,  and  independent  of  the  common  parietal 
seats  of  hernia,  there  may  be  said  to  exist  within  the  abdomen 
four  situations  in  which  a  loop  of  intestine  may  become 
strangulated.  Three  of  these  are  classed  as  retroperitoneal ; 
the  bowel  passes  into  fossae  which  are  formed  of  pouches  of 
peritoneum  lying  between  the  parietal  layer  of  that  membrane 
and  the  muscles.  One  of  these  fossae  is  known  as  the  '  duodeno- 
jejunal '  and  is  situated,  as  the  name  implies,  at  the  end  of  the 
duodenum,  close  to  its  junction  with  the  jejunum.  The  pocket 
which  normally  exists  there  is  formed  by  the  reflection  of  the 
parietal  peritoneum  to  the  duodenum. 

A  second  is  that  known  as  the  '  pericecal,'  and  com- 
prises several  fossEe  situated  around  that  particular  portion 
of  the  bowel ;  the  commonest  seat  is  behind  the  csecum — 
'  retrocsecal.' 

The  third  is  termed  '  intersigmoid  ;  '  a  fossa  which  is 
found  at  the  root  of  the  pehic  meso-colon. 

The  fourth  seat  of  internal  hernia,  through  a  natural 
aperture,  is  that  through  the  foramen  of  Winslow. 

In  cases  where  acute  strangulation  occurs  in  one  of  these 
situations,  it  is  not  always  easy  to  determine  the  exact 
position  of  the  peritoneal  pouch  at  the  time  of  operation.  It 
is  only  when  a  careful  post-mortem  dissection  is  made 
that  the  situation  of  the  constricting  fossa  can  be  accurately 
located.  Thus  in  many  of  the  recorded  cases  the  nature  of 
the  hernia  is  only  indefinitely  stated,  and  it  is  not  possible  to 
classify  it  in  one  or  other  of  the  situations  above  deFcribed. 

In  a  case  recorded  by  Jackson  Clarke,'  the  sac  is  described 
'  as  consisting  of  that  part  of  the  mesentery  which  lies 
between  tbe  superior  mesenteric  vessels  and  the  attachment 
of  the  mesentery  to  the  posterior  abdominal  wall,'  and  would 
therefore  appear  to  be  of  the  duodeno-jejunal  variety.  In  a 
case  reported  by  Robson,^  a  loop  of  small  intestine  became 

'  Trans.  Path.  Soc.  Land.  1893,  vol.  xliv.  p.  G7. 
=  Brit.  Mei.  Journ.  1889,  vol.  i.  p.  G5G. 


INTERNAL   IIEKNIA  351 

involved  in  an  opening  in  the  parietal  peritoneum,  about  an 
inch  above  the  crest  of  the  ileum  on  the  right  side.  This  case 
would  appear  to  be  an  illustration  of  the  retrocae.cal  variety. 
Another  case  of  the  duodeno-jejunal  form,  and  similar  there- 
fore to  Clarke's,  is  recorded  by  A.  G.  Barrs.'  Pye-Smith  and 
Astley  Cooper  ^  have  also  reported  cases,  the  former  having 
treated  the  subject  somewhat  fully.  The  reader,  however, 
who  wishes  to  consult  one  of  the  most  complete  and  exhaustive 
disquisitions  upon  the  subject  is  referred  to  the  work  by 
Jonnesco.^ 

Case  LXXIII. — Hernia  of  a  2}ortion  of  the  ileum  into  the  fossa  duodeno- 
jejunalis  :  strangulation  :  la^parotomy.  Death. 
A  man  aged  21  years  was  admitted  into  hospital  on  August  21,  1892. 
Two  days  before  he  had  been  attacked  by  sudden  pain  referred  to  the 
right  iliac  region,  and  with  vomiting.  The  pain  became  so  severe  as  to 
require  hypodermic  injections  of  morphia  for  its  relief.  The  vomiting 
became  persistent,  the  constipation  complete,  and  the  prostration  extreme. 
Tenderness  was  more  marked  beneath  the  right  rectus  muscle  and  below 
the  level  of  the  umbilicus  than  elsewhere.  A  median  mcision  was  made, 
when  a  hernia  of  a  portion  of  the  ileum  into  the  fossa  duodeno-jejunalis 
was  found.  The  patient  failed  to  rally,  and  died  in  twelve  hours.  The 
symptoms  resembling  so  much  those  of  appendicitis,  it  was  thought  to 
be  probably  a  case  of  that  nature.  (George  Eyerson  Fowler,  '  Annals  of 
Surgery,'  1894,  vol.  xix.  p.  166.) 

(B)  Strangulation  through  adventitious  or  congenital  aper- 
tures.—  Cases  occasionally  o'ccur  where  a  loop  of  intestine 
becomes  strangulated  through  a  slit  or  aperture  in  some 
membranous  expansion,  either  normal  or  pathological.  Thus, 
as  the  result  usually  of  some  antecedent  accident,  a  slit  is 
produced  in  the  mesentery,  and  through  this  a  loop  of  bowel 
slips  and  becomes  strangulated.  In  other  instances  the  slit 
has  been  formed  in  a  membranous  band  or  expansion  the 
result  of  stretched  adhesions.  In  illustration  of  the  former, 
Hector  Cameron  ^  alluded  to  a  case  in  the  discussion  on  acute 
intestinal  obstruction,  held  in  Glasgow,  of  a  man  who  had  been 
kicked  in  the  abdomen  a  year  or  two  previously.  The  injury 
resulted    at   the  time  in  a  very  serious   illness,  followed  by 

'  Lancet,  1891,  vol.  ii.  p.  286. 

^  Guy^s  Hosintal  Eejjorts,  1871,  vol.  xvi.  p.  1.31. 

^  Hernies  Internes  Eitro-perltoneales,  1890. 

<  Trans.  Path,  and  Clin.  Soc.  Glasgow,  189-3,  vol.  iv.  p.  78. 


352  THE   JEJUNUM   AND   ILEUM 

vomiting  and  abdominal  distension.  The  patient  when  seen 
on  the  present  occasion  was  moribund  from  acute  obstruction. 
At  the  post  mortem,  it  was  found  that  '  the  mesentery  had 
been  torn  away  at  one  point  from  its  attachment  to  the  bowel, 
and  through  a  round  hole  thus  produced,  a  loop  of  gut  had 
passed,  been  strangulated  and  rendered  gangrenous.' 

In  some  cases  it  would  appear  that  these  slits  in  the 
mesentery  may  be  of  congenital  origin.  Such,  for  instance, 
seems  to  have  been  the  explanation  of  a  specimen  exhibited 
by  Joseph  Coats  '  at  the  same  discussion.  The  edges  of  the 
aperture  in  the  mesentery  through  which  the  small  intestine 
had  passed  and  become  strangulated  were  smooth,  rounded, 
and  presented  no  appearance  of  a  recent  scar.  In  a  case 
recorded  by  Eushton  Parker,^  where  a  loop  of  ileum  passed 
through  an  aperture  in  the  mesentery  and  became  strangu- 
lated, the  mesenteric  perforation  was  supposed  to  be  due 
to  a  perityphlitis,  from  which  the  patient  had  suffered  some 
time  previously. 

The  only  case  of  this  kind  which  has  come  under  my 
own  observation,  I  believe  to  have  been  an  illustration  of  an 
adventitious  aperture.  About  four  feet  of  the  ilaum,  eight 
inches  above  the  ileo-csecal  valve,  had  passed  through  an  aper- 
ture in  the  mesentery  close  to  its  spinal  attachment.  The 
edges  of  the  opening  were  thickened  and  smooth.  The  bowel 
was  acutely  constricted,  and  the  four  feet  ensnared  were  in 
an  advanced  state  of  gangrene.  The  history  of  the  case,  as 
detailed  below,  tends  to  show  that  some  lesion  of  the  mesentery 
took  place  three  years  previously,  when  the  child  was  run 
over  by  a  cart. 

Case  LXXIV. — Strangulation  of  the  ileum  through  an  aperture  in  the 
tnesentery :  operation.     Death. 

J.  G.,  aged  12  years,  was  admitted  to  the  Victoria  Infirmary  at  7  a.m. 
on  Monday,  June  24,  1895.  His  symptoms  commenced  on  the  previous 
Thursday  (June  20)  by  a  severe  attack  of  colic.  This,  however,  passed 
off,  and  on  the  following  day  (Friday)  he  was  back  at  school,  apparently 
in  his  usual  health.  On  Saturday  he  was  away  at  a  school  trip,  and  does 
not  appear  to  have  suffered  in  any  way.  His  bowels  had  not  been  moved, 
and  as  on  Sunday  morning  he  was  again  seized  with  severe  colic,  his 

'  Trans.  Path,  and  Clin.  Sac.  Glasgow,  1893,  vol.  iv.  p.  57. 
-  Brit.  Med.  Journ.  1893,  vol.  ii.  p.  1373. 


IXTERXAL    TI]:i{NIA  353 

parents  administerecl  some  aperient  medicine  ;  lliis  was  vomited,  and  from 
henceforth  the  attempt  to  take  anything  was  followed  by  its  ejection. 
The  pain  continuing,  and  the  boy  looking  much  worse,  he  was  brought 
to  the  infirmary.  On  admission,  he  was  in  a  somewhat  drowsy  state, 
lying  partly  on  his  side,  with  his  thighs  slightly  flexed  upon  the  abdomen. 
There  was  pallor  of  the  cheeks,  and  some  darkness  and  depression  below 
the  eyes.  Skin  cool,  no  perspiration.  No  complaint  of  pain  except  when 
the  abdomen  was  handled.  Eespiration  partly  thoracic.  Tongue  moist ; 
complained  of  thirst ;  vomited  occasionally  a  little  mncus ;  but  vomiting 
had  not  been  a  marked  feature,  and  usually  associated  with  taking  any- 
thing by  the  mouth.  No  passage  of  feeces  or  flatus,  no  urine  passed. 
Pulse  about  150  and  very  feeble.     Temperature  99^  F. 

On  examination  of  the  abdomen  the  parietes  were  found  rigid :  there 
was  some  distension  :  no  visible  peristalsis.  On  percussion  a  resonant 
sound  was  obtained  all  over ;  the  note,  however,  was  dulled  in  the  lower 
regions.  Palpation  caused  pain,  especially  over  the  iliac  and  hypogastric 
regions.  At  11.30  a.m.,  four  and  a  half  hours  after  admission,  and  the 
fifth  day  after  the  onset  of  the  symptoms,  the  abdomen  was  opened. 
A  fjuantity  of  blood-stained  fluid  immediately  escaped.  It  possessed 
an  unpleasant,  close  odour,  but  not  distinctly  fgecal.  Some  distended, 
almost  black,  coils  of  intestine  presented.  A  search  soon  revealed  the 
natiire  of  the  condition.  A  long  loop  of  ileum — about  four  feet — at  a 
distance  of  eight  inches  from  the  ileo-csecal  valve,  had  passed  through  an 
aperture  in  the  mesentery  close  to  its  spinal  attachment.  The  opening, 
which  appeared  small  enough  to  admit  only  the  tip  of  the  little  finger, 
was  enlarged  and  the  bowel  withdra^\'n.  The  bowel  was  completely  gan- 
grenous, and  had  therefore  to  be  removed.  The  free  ends  of  the  normal 
intestine  were  approximated  by  a  medium-sized  Murphy's  button,  and  the 
rent  in  the  mesentery  stitched  up.  The  abdominal  cavity  was  finally 
freely  flushed  out  with  hot  water.  At  this  stage,  however,  the  pulse  failed, 
and  the  patient,  who  had  been  gradually  looking  much  worse,  succumbed 
just  at  the  completion  of  the  operation,  which  had  lasted  a  little  under 
the  hour. 

It  was  subsequently  ascertamed  from  the  friends  that  the  boy,  three 
3'ears  before,  was  run  over  by  a  cart,  the  wheel  passing  obliquely  across 
the  thorax  and  abdomen.  He  complained  of  pain  in  the  abdomen,  which 
Avas  reUeved  by  hot  fomentations  and  opium.  He  was  kept  in  bed  for  a 
week,  after  which  he  got  up  and  had  remained  well  until  his  present 
attack.     (A.  Ernest  Maylard,  Clinical  Pieports,  1895.) 

Well  as  this  boy  appears  to  have  been  between  his  attack 
of  colic  on  the  Thursday  morning  and  his  second  attack  on 
Sunday  morning,  it  hardly  seems  possible  that  the  advanced 
condition  of  gangrene  which  existed  had  arisen  within  the 
thirty  hours  which  elapsed  between  the  operation  and  his 
second  seizure.  It  is  probable  that  some  engagement  of  the 
loop  had  taken  place  on  the  first  day,  and  that  no  action  of 

A  A 


354  THE   JEJUNUM   AND   ILEUM 

the  bowals  took  place  after  seems  further  to  support  such  a 
view.  If  this  be  the  correct  aspect  of  the  case,  it  remains  a 
remarkable  fact  that  for  the  two  intervening  days  the  boy  was 
going  about  as  usual,  with  no  evidence  of  any  illness  or  even 
discomfort.  But  for  the  history  of  an  accident,  the  smooth 
and  thickened  edges  of  the  aperture  might  have  suggested  its 
congenital  origin.  With,  however,  such  clear  and  unmistak- 
able evidence  of  an  accident  so  likely  to  produce  the  very 
lesion  found,  there  is  no  need  to  suspect  a  cause  which, 
independently  of  its  giving  rise  to  strangulation,  is  so  little 
known. 


CHAPTEE  XLII 


INTEENAL    HERNIA  {continued)  :    (c)    UNDER    BANDS,    CORDS, 
DIVERTICULA,  &C. 

In  the  larger  number  of  cases  of  internal  strangulation  the 
cause  is  found  to  be  some  form  of  band.  It  is  usual  to  classify 
bands  according  to  the  structure  out  of  which  they  are  formed. 
It  is  thus  possible  to  differentiate  three  kinds  : 

(1)  Adventitious,  the  result  of  stretched  adhesions. 

(2)  Meckel's  diverticulum. 

(B)  Normal  anatomical  structures. 

(1)  Adventitious  hands  arise  usually  from  some  antecedent 
local  inflammation  which  has  led  at  the  time  to  a  local  peri- 
tonitis. The  resulting  adhesions  subsequently  stretch  and 
give  rise  to  bands,  solitary  or  multiple,  which  in  various  ways 
cause  strangulation  of  the  bowel. 

Some  of  the  commonest  causes  of  these  local  peritoneal 
attacks  are,  inflammation  around  the  caecum  and  appendix ; 
pelvic  cellulitis  ;  ulceration  of  bowel ;  inflamed  mesenteric 
glands ;  abdominal  operations  ;  operations  for  external  her- 
nife ;  and  injuries. 

In  cases  where  the  bands  are  multiple,  the  previous  peri- 
tonitic  attack  has  been  general  rather  than  local ;  and  in  such 
instances  the  cause  is  usually  found  to  be  tuberculosis.  Of 
six  cases  of  strangulation  by  bands,  reported  by  Joseph  Coats 
at  the  Glasgow  discussion  above  referred  to,  four  owed  their 
orioin  to  healed  tuberculosis 


INTERNAL   HERNIA    UNDER   BANDS   ETC. 


355 


Eegarding  the  si^e,  length,  and  attachments  of  these 
adventitious  bands  the  utmost  variation  exists  ;  and  for  a 
fiiU  and  detailed  account  of  these  conditions  the  reader  cannot 
do  better  than  consult  Treves's  excellent  monograjDh  on  Acute 
Intestinal  Obstruction,  or  Leichtenstern's  classical  article  in 
Ziomsseu's  '  Cyclopaedia  of  Medicine.' ' 
It  may,  however,  be  briefly  noted 
here  that,  inasmuch  as  the  chief 
determining  feature  of  the  position 
and  attachment  of  a  band  is  the 
situation  of  the  inflammatory  focus 
to  which  it  owes  its  origin,  bands  may 
be  expected  to  be  found  running  be- 
tween any  parts  or  structures  which 
have  become,  by  natural  proximity, 
glued  to  the  primary  seat  of  inflam- 
mation. Thus,  then,  bands  may  be 
found  extending  between  two  portions 
of  bowel  (see  fig.  48),  between  bowel 
and  parietes,  between  bowel  and 
mesentery  or  omentum,  between  the 
■  bowel  or  parietes  and  any  of  the  female 
pelvic  organs. 

In  cases  where  adhesions  form  between  the  bowel  and  the 
mesentery  or  omentum,  these  latter  are  liable  to  be  drawn 
upon  so  as  to  constitute  in  themselves  cords  capable  of 
strangulating  a  loop  of  intestine. 

There  are  numerous  ways  bj'  which  a  band  may  cause 
obstruction.  One  of  the  most  frequent  and  simplest  is  for  a 
loop  of  small  intestine  to  slip  beneath  the  cord,  which  if  not 
tense  at  the  time  may  rapidly  become  so.  A  loop  thus  caught, 
sometimes  rotates,  and  if  not  actually  strangulated  by  the  band, 
becomes  completely  obstructed  by  the  accidentally  produced 
volvulus.  A  most  complicated  method  of  strangulation  is  for 
the  bowel  to  become  snared  by  a  knot  or  noose.  This  can 
only  happen  when  the  band  is  sufficiently  long  and  the 
mesentery  admits  of  the  torsion  and  movement  of  the  gut 
necessary  for  its  production. 


Fig.  48 — Steangtjlation  op 
A  Loop  of  SaiAiL  Intes- 
tine BY  A  FiBKOus  Band 

PASSING  BETWEEN  THE  TWO 
PARTS  OF  THE  GuT  AND 
FOKMING     A    KNOT     ABOUND 

A  LOOP.  (Museum  '  Cata- 
logue,' Western  Infirmary, 

Glasgow) 


'  Vol.  vii.  p.  501. 


A    A    2 


356  THE   JEJUNUM   AND   ILEUM 

(2)  MeckeVs  diverticulum. — This  constitutes  the  remnant  of 
the  vitelHne  duct.  It  is  usually  found  about  thirty  inches 
from  the  ctecum,  and,  according  to  Allen, ^  may  be  found  at 
any  spot  between  fifteen  inches  and  three  feet  from  the  ileo- 
csecal  valve.  It  varies  considerably  in  length  and  patency. 
From  forming  a  simple  pouchlike  projection  from  the  ileum, 
it  may  extend  to  the  umbilicus,  where,  when  patent,  it  con- 
stitutes one  of  the  forms  of  umbilical  fistula.  In  some  cases 
the  diverticulum  is  only  patent  throughout  a  certain  portion 
of  its  extent,  the  remaining  part  being  little  more  than  a  fibrous 
band. 

The  diverticulum,  when  unconnected  with  the  umbilicus, 
may  remain  free  in  its  distal  extremity  or  become  attached 
to  some  neighbouring  organ  or  tissue.  In  both  conditions  it 
is  capable  of  strangulating  a  loop  of  intestine.  When  free,  it 
strangulates  by  tying  a  simple  knot  round  the  bowel  ;  when 
attached,  it  constitutes  a  band  beneath  which  a  loop  slips,  and 
becomes  strangulated  as  in  the  case  of  adventitious  cords.  As 
illustrating  this  latter  method,  a  case  which  came  under  my 
observation  affords  a  good  example  (see  fig.  50).  The  diver- 
ticulum was  attached  by  its  apex  to  a  band  which  itself  was 
adherent  to  some  enlarged  glands  in  the  mesentery.  Beneath 
this  a  loop  of  ileum  slipped  and  became  strangulated.  Addi- 
tional interest  attaches  to  the  case  from  the  effect  produced 
by  the  tension  of  the  band  upon  the  diverticulum.  This  latter 
^Yas  found  to  be  gangrenous  in  almost  its  entire  length. 
Oderfeld  ^  reports  a  somewhat  similar  case  where  the  diverti- 
culum was  attached  to  the  mesentery. 

(3)  Strangulation  jjroduced  by  normal  structures. — The  vermi- 
form appendix,  the  Fallopian  tube,  the  appendices  epiploicse, 
by  becoming  attached  to  neighbouring  parts,  may  form  bands 
beneath  which  coils  of  bowel  can  pass  and  become  stran- 
gulated. 

In  the  case  of  the  two  former  it  usually  arises  from  some 
inflammatory  mischief  connected  with  the  part.  This,  by 
causing  a  localised  peritoneal  inflammation,  leads  to  a  per- 
manent adhesion,  which,  as  the  result  of  subsequent  traction, 
becomes  drawn  out  into  a  bandlike  form.     In  the  case  of  the 

'  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  iii.  C— 56. 
-  Lancet,  1802,  vol.  i.  p.  273. 


INTERNAL   HERNIA   UNDER   JJANDS   ETC. 


^57 


appendices  epij)loicaB,  it  is  these  latter  which  become  attached 
by  a  local  peritoneal  adhesion,  either  to  each  other  or  to  some 
neighbouring  part.  In  illustration  of  the  former  method  two 
interesting  cases  recorded  by  Perry  '  are  worthy  of  notice.  In 
the  first  '  a  loop  four  or  five  inches  long  had  slipped  between 
two  adjacent  appendices  which  were  united  by  five  thin  adhe- 
sions at  their  tips.  The  pair  of  appendices  were  situated  ten 
inches  from  the  lower  end  of  the  rectum,  and  lay  about  two 
inches  to  the  left  of  the  vertebral  column  at  the  level  of  the 


Fia.  50. 


-Stkangulation  of  a  Loop  of  small  Intestine  beneath 
Meckel's  Diverticulum 


a,  Meckel's  diverticulum  witli  cord  h  passing  to  enlarged  glands  c  in  mesenteiy  ;  rf,  appendix 
attached  to  CEecum  e,  and  colon  ;  /,  dilated  small  intestine ;  g,  ensnared  loop 


fifth  lumbar  vertebra.'  In  the  second,  *  about  twelve  inches 
from  the  lower  end  of  the  rectum  on  the  left  side,  just  below 
the  brim  of  the  pelvis,  a  pair  of  appendices,  with  their  adjacent 
sides  deeply  congested,  came  into  view,  and  their  tips  showed 
a  rent  in  the  serous  covering  as  though  they  had  been  sepa- 
rated from  each  other.' 

Among  normal  structures  causing  bands  should  also  be 
included  the  omentum  and  mesentery ;  for  these,  becoming 
attached  to  some  other  spot,  may  be  so  drawn  out  as  to  con- 
stitute definite  constricting  agents. 

'   Trans.  Path.  Soc.  Lond.  1889,  vol.  xl.  p.  93, 


358  THE   JEJUNUM   AND   ILEU]\r 

The  method  by  which  strangulation  beneath  a  band  is  effected. 

It  is  not  difficult  to  understand  the  mode  by  which  a  loop 
of  bowel  is  strangulated,  if  the  analogy  which  this  form  of 
strangulation  presents  to  that  of  an  ordinary  external  hernia 
be  borne  in  mind. 

It  may  be  that,  like  an  ordinary  hernia,  a  loop  of  intestine 
frequently  finds  its  way  beneath  the  band,  but  some  altered 
position,  or  other  agency,  causes  it  to  slip  out  again ;  or  that 
a  loop,  instead  of  returning  to  its  normal  condition,  becomes 
permanently  retained,  and,  if  not  immediately,  probably  within 
a  short  time,  strangulated. 

In  some  instances  it  is  not  a  matter  of  a  loop  slipping 
beneath  a  band,  but  of  a  band  passing  transversely  across  a 
section  of  the  gut.  In  such  cases  the  initial  processes  which 
bring  about  strangulation  are  frequently  slow.  Any  sudden 
over-distension  of  the  bowel  above  the  band  may  cause  pain 
and  vomiting,  which  pass  off  so  soon  as  the  obstruction  is 
relieved.  But  these  attacks  become  repeated,  until  one  at  last 
proves  sufficient  to  bring  about  a  complete  strangulation  of  the 
gut,  at  the  point  where  it  is  crossed  by  the  band. 

The  changes  which  bring  about  the  retention  of  a  loop 
beneath  a  band  mostly  concern  the  bowel  itself.  In  some  cases 
the  bowel,  after  it  passes  beneath  the  band,  becomes  twisted  ;  so 
that,  while  the  band  proves  to  be  the  cause  of  the  volvulus,  it 
is  the  latter  which  becomes  the  direct  means  of  producing  the 
obstruction.  In  most  instances,  however,  it  is  probable  that 
the  changes  which  follow  on  constriction  of  the  gut  resemble 
those  consequent  on  the  strangulation  of  an  ordinary  external 
hernia.  Either  some  gas  finds  its  way  into  the  loop,  or  is 
generated  within  it,  and  so  distends  it  that  the  proper  blood 
supply  to  the  part  is  interfered  with,  or  the  constriction 
itself  so  directly  compresses  the  mesentery  that  its  vessels  at 
once  become  practically  occluded.  The  immediate  result  in 
either  case  is  distension  of  the  ensnared  loop  and  engorgement 
of  the  intestinal  walls.  Unless  this  condition  be  rapidly  re- 
lieved, gangrene  soon  follows. 

Symptoms. — Internal  strangulation,  whether  produced  by 
bands  or  by  apertures  in  the  mesentery  and  other  membranous 
expansions,  or  by  retroperitoneal  pouches,  almost  invariably 
gives  rise  to  a  series  of  sudden  and  acute  symptoms.     It  must. 


PLATE    XVI. 


Fig.  4g. — Meckel's  Diverticulum. — It  is  in  the  form  of  an  elongated  pouch  about 
iK  inches  in  length,  and  of  about  the  same  calibre  as  the  intestine.  It  was 
situated  about  three  feet  above  the  ileo-ccecal  valve.     [H'.I.CM.,  Glas.) 


IXTEItNAL   IIEPtNIA    UNDER   BANDS   ETC.  3o9 

however,  be  remembered,  on  the  other  hand,  that  it  is  possible 
for  a  loop  to  be  onl}^  temporarily  caught,  and  for  the  symptoms, 
rapid  in  their  origin,  as  rapidly  to  disappear.  In  numerous 
instances  of  acute  obstruction  due  to  one  of  tlipse  causes, 
there  have  been  well-marked  histories  of  acute  attacks  of  colic, 
with  sometimes  vomiting  and  other  abdominal  disturbances 
which,  though  transitory  and  obscure  at  the  time,  have  been 
clearly  due  to  the  same  cause  which  has  brought  about  the 
fatal  attack. 

In  considering  therefore  the  symptoms  of  this  class  of 
case,  no  more  instructive  method  can  be  adopted  than  by 
showing  their  analogy  to  those  which  follow  upon  the  anatomi- 
cally and  pathologically  similar  conditions  connected  with 
external  hernia. 

A  patient  accustomed  to  return  the  bowel  from  an  old 
inguinal  or  femoral  sac,  finds  that,  from  some  cause,  he  is 
unable  to  do  so  ;  pain  and  discomfort  then  commence  to  be 
felt  in  the  part.  As  the  bowel  becomes  gradually  strangulated, 
vomiting  sets  in,  there  is  obstipation,  some  abdominal  pain, 
and  general  appearance  of  anxiety  or  depression.  Such  also 
may  be  the  mode  of  attack  in  a  case  of  internal  strangulation  ; 
only,  when  once  the  bowel  has  become  definitely  strangulated, 
the  abdominal  symptoms  present  a  more  striking  feature. 
The  abdominal  pain  will  be  acute,  the  vomiting  more  urgent 
and  persistent,  and  the  physical  expression  of  the  patient 
suggestive  of  grave  internal  mischief. 

In  cases  of  hernife  into  a  congenital  sac,  hitherto  unoccu- 
pied by  a  loop  of  bowel,  we  have  frequently  the  acutest  form 
of  external  strangulation,  where  the  symptoms  commence 
sharply,  or  rapidly  become  acute.  Such  is  the  probable  ex- 
planation of  those  very  acute  cases  of  internal  strangulation 
where  the  patient,  perfectly  well  at  the  time,  is  suddenly 
struck  down  by  the  most  agonising  abdominal  pain,  a  pain 
which  doubles  him  up,  causes  vomiting,  and  is  often  followed 
by  much  collapse.  As  time  progresses,  the  pain  sometimes 
abates  somewhat,  but  only  to  return  again  with  renewed 
severity.  In  other  cases  it  remains  more  or  less  constant,  and 
the  vomiting  continues  until  it  assumes  a  faecal  character. 
This  latter  state  is  not  generally  reached  till  the  fourth  or  fifth 
day.     Neither  faeces  nor  flatus  is  passed.     The  abdomen  does 


360  THE   JEJUNUM    AND   ILEUM 

not  usually  show  any  marked  distension,  meteorism  being  a 
later  symptom,  and  indicative  of  peritonitis.  Palpation  of  the 
abdomen  may  reveal  some  tenderness.  While  the  pulse,  tem- 
perature, and  respiration  may  be  normal  for  the  first  day 
or  two,  some  rise  may  take  place  later  ;  more  frequently, 
however,  the  temperature  falls,  sometimes  being  subnormal. 
The  tongue,  clean  and  moist  at  the  outset,  becomes  dry  and 
foul  later,  and  when  fsecal  vomiting  has  set  in,  great  thirst 
is  frequently  complained  of.  The  urine  is  usually  scanty. 
The  patient's  mental  condition  remains  intact,  but  the  face 
often  exhibits  an  aspect  of  anxiety  ;  the  features  are  pinched, 
and  the  eyes  sunken  and  darkly  underlined.  Perspiration  is 
sometimes  profuse,  and  is  seen  to  hang  in  innumerable  drop- 
lets upon  a  pale  and  cold  forehead.  Cases,  however,  frequently 
occur  where,  beyond  pallor,  the  skin  of  the  face  is  but  little 
altered. 

If  the  patient  lives  long  enough,  and  no  operative  measures 
are  undertaken,  peritonitis  sets  in.  The  abdomen  now  begins 
to  distend,  the  pulse  grows  weaker  and  more  rapid,  some  rise 
of  temperature  takes  place,  the  respiration  becomes  shallower, 
more  rapid,  and  partakes  more  of  the  thoracic  character  ; 
vomiting,  if  not  so  violent,  remains  continuous,  and  death  may 
be  ushered  in  by  slight  convulsions. 

Such  is  a  brief  outline  of  the  course  which  an  ordinary 
more  or  less  typical  acute  attack  may  take.  But,  just  as  in 
the  case  of  external  strangulated  hernite,  so  with  internal 
strangulation,  the  amount  of  collapse,  or  the  degree  and  fre- 
quency of  pain  ;  the  violence  and  persistency  of  the  vomiting ; 
the  rapidity  with  which  the  symptoms  succeed  eacji  other, 
may  all  vary  within  wide  limits  ;  and  the  variation  is  probably 
dependent  upon  the  acuteness  of  the  strangulation,  and 
the  disposition  of  the  patient's  nervous  system.  How  slight 
may  be  the  symptoms  in  some  instances  is  well  shown  in  a 
case  reported  by  Marsh. ^  A  boy  was  attacked  with  sickness 
after  taking  some  unripe  fruit,  but  there  was  only  slight  pain. 
The  sickness  remained  for  a  day  or  two,  when  suddenly  on 
the  sixth  day  it  returned  and  was  fsecal.  Throughout  there 
was  but  little  pain,  no  abdominal  distension,  but  no  movement 

'  Lancet,  1893,  vol.  i.  p.  588. 


INTERNAL   HERNIA   UNDER   J3ANDS   ETC.  361 

of  the  bowels.     The  abdomen  was  opened,  a  band  removed, 
and  the  boy  recovered. 

Diagnosis. — Eegarding  the  symptoms  as  j)resent  in  an 
acute  case,  there  cannot  be  said  to  be  any  which  it  is  possible 
to  look  upon  as  pathognomonic.  So  many  causes  of  abdominal 
affections  give  rise  to  an  almost  precisely  similar  train  of 
symptoms  at  the  outset  that  in  a  vast  majority  of  cases  a 
diagnosis  can  be  little  more  than  conjectural.  Importance, 
however,  should  always  be  attached  to  the  previous  history. 
It  has  been  shown  how  frequently  the  bands  which  give  rise 
to  strangulation  owe  their  origin  to  some  distinct  antecedent 
inflammatory  cause.  So  that  any  history  of  an  attack  of 
appendicitis,  of  pelvic  mischief  in  the  female,  of  abdominal 
injury,  of  tubercular  peritonitis,  of  tabes  mesenterica,  of 
abdominal  operations,  and  of  operations  for  external  hernise 
should  be  well  considered,  as  also  the  history  of  any  previous 
attacks  of  colic,  vomiting,  or  intestinal  disturbance.  Oder- 
feld  '  states  that  the  existence  of  hare-lip  or  the  history  of  an 
umbilical  fistula — features  which  suggest  a  tendency  to  some 
maldevelopment — should  direct  the  attention  to  the  possible 
existence  of  Meckel's  diverticulum. 

While,  as  shown  by  Leichtenstern's  statistics  quoted  by 
Treves,^  acute  obstruction  from  bands  is  slightly  more  frequent 
in  males  than  in  females,  and  is  commoner  between  the  ages  of 
20  years  and  40  years  than  at  other  periods,  the  frequency 
in  neither  case  is  sufficient  to  be  of  any  practical  service  for 
diagnostic  purposes. 

"When  internal  strangulation  occurs  in  children,  at  which 
age  intussusception  is  most  common,  the  absence  of  any  dis- 
tinct tumour,  as  also  the  absence  of  any  discharge  of  mucus 
and  blood  j^ei-  rectum,  should  lead  the  surgeon  to  suspect  the 
possible  existence  of  strangulation  by  band  ;  although  it  must 
be  remembered  that  the  absence  of  these  symptoms,  as  will 
be  shown  later,  does  not  necessarily  preclude  even  the  possi- 
bility of  intussusception. 

How  rapidly  a  band  may  form  capable  of  producing 
strangulation  is  well  shown  in  a  case  recorded  by  Franklin.^ 
The  patient  received  a  severe  blow  upon  the  abdomen.     Four 

'  Lancet,  1892,  vol.  i.  p.  273.  -  Page  63. 

^  Lancet,  1892,  vol.  i.  p.  27a. 


362 


THE   JEJUNUM   AND   ILEUM 


days  after  the  accident  severe  abdominal  pain  commenced, 
followed  by  vomiting  two  days  later,  which  rapidly  became 
faecal.     The  band  consisted  of  lymph. 

Treatment.— If  we  continue  the  analogy  between  internal 
and  external  strangulation  into  the  question  of  treatment, 
then  we  have  but  one  course  open  to  us,  and  that  is  to  operate. 
No  surgeon  would  delay  to  relieve  a  loop  of  gut  strangulated 
in  any  one  of  the  usual  external  apertures  ;  neither  should  he 
hesitate  to  disengage  a  portion  of  bowel  similarly  situated  in 
any  other  part  of  the  body. 

Ample  proof  is  forthcoming  of  the  value  of  opening  the 
abdomen  and  liberating  the  ensnared  loop.  I  have  collected 
in  the  subjoined  table  cases  which  have  been  published  since 
1890,  of  successful  operations  performed  for  this  form  of 
strangulation.  It  did  not  seem  to  me  that  any  useful  purpose 
would  be  served  by  quoting  also  the  unsuccessful  cases,  for 
the  very  good  reason  that  no  fair  comparison  can  be  drawn. 
It  is  possible  that  every  successful  case  is  published,  but  it  is 
certain  that  every  unsuccessful  one  is  not.  So  that  all  that 
is  really  needful  is  to  show  from  a  sufficiently  large  number 
of  successful  cases  that  the  operation  does  afford  unmistakable 
evidence  of  curing  an  otherwise  incurable  and  rapidly  fatal 
condition. 

Table  of  Successful  Operations  for  Internal  Strangulation 
from  1891  to  1895  inclusive 


Time  intervening 

Operator 

Nature  of  Con- 
striction 

between  onset  of 

symptoms  and 

operation 

Nature  of 
Operation 

Beference 

Moaiprofit 

Baud 

4  days 

Laparotomy 
and  division 
ol  band 

Revile  de  Chirurgie, 
1891,  p.  405 

Rabagliati 

Band      (tag     of 
omentum     at- 
tached to  small 
gut) 

Baud     (attached 

5    „ 

" 

Med.  Press  orirj  Cir- 
cular, 1891,  ii. 
679 

E.  J.  Cave 

4    „ 

Lancet,     1891,      ii. 

to  the  umbili- 

(fsecal vomiting) 

1213 

cus) 

Boiffin      . 

Band 

5  days 

" 

Med.  Press  and  Cir- 
cular, 1892,  i. 
422 

3J 

Band 

6    „ 

Ibid. 

Irving 

Band 

3    „ 

" 

Brit.  Med.  Journ. 
1892,  i.  916 

Coates 

Baud 

12    „ 

Ibid.  p.  864 

INTERNAL  HERNIA  UNDER  BANDS  ETC. 


3(J3 


Time  intervening 

Nature  of  Con- 

between onset  of 

Nature  of 

Reference 

Operator 

striction 

symptoms  and 

0,_eration 

operation 

NiooUii'sen 

Band    consi  ting 

5  days 

Laparotomy 

Brit.  Med.   Jo  urn. 

of        appendix 

and    separa- 

18'J2, ii.  17u 

winch    fo.'Uied 

tion  of  baud 

lialf     a     knoD. 

Tlie   loop   was 

also  twibted 

Oderfekl  . 

Band     (Meckel's 
diverticulum) 

Kot  given 

Laparotomy 
and  removal 
of  diverticu- 
lum 

Lancet,  1892,  i.  273 

G.  A.  Wright  . 

Band       (passing 
between      two 
portions         of 
bowel) 

10  days 

Laparotomy 
and  division 
of  band 

Ibid.  ii.  144 

Soutliam  . 

Band       (passing 

10      „ 

jj 

Brit.    Med.   Jo  urn. 

from  the  vici- 

(ffecal vomiting) 

1893,  ii.  373 

nity    of    some 

enlarged  glands 

to  meseiuery) 

Eushton  Parkei 

Strangulation  of 
ileum  through 
an  aperture  in 
the  mesentery 

3  days 

Laparotomy 
and     reduc- 
tion   of    the 
hernia 

Ibid.  p.  1373 

Franklin  . 

Band  (composed 
of            lymph 
lormed       four 
days  after  blow 
on  abdomen) 

3    „ 

Laparotomy 
and    separa- 
tion of  band 

Lancet,  1893,  ii.  748 

Howard  Marsh 

Baud 

6     „ 
(fa3cal  vomiting) 

Laparotomy 
and  division 
of  band 

Ibid.  i.  588 

Broca 

Band 

Not  given 

" 

Ann.  Univ.  Med.  Sci. 
1893,iii.  C— 56 

Dean 

Band 

Not  given 

" 

Brit.    Med.    Journ. 
1894,  1.752 

Hutchinson     . 

Band  (extending 
from     gut    to 
linea  aloa) 

15  hours 

" 

Ibid. 

H.  Butcher      . 

Band     (Meckel's 
diverticulum) 

10  days 
(fsecal  vomiting) 

" 

Ibid.  p.  1078 

J, 

Band  (drawn-out 

3  days 

Ibid. 

tag    of    omen- 

" 

tum) 

Cave 

Band    (attached 
by  one  end  to 
tlie  ba(^k  of  the 
abdomen    near 
the  lelt  pelvic 
brim,  the  other 
deep     in     the 
pelvis) 

(ffecal  vomiting) 

Ibid.  ii.  67 

E.  Jones  . 

Band  (extending 
from  tlie  direc- 
tion     of     the 
right  kidney) 

12  days 

(4  days  of  tajcal 

vomiting) 

" 

ma. 

Koch 

Baud 

3  days 

" 

Brit.  Med.   Journ. 
Epitome,  1894,  i. 
18 

Bbrfler     . 

Band 

2     ■, 

Laparotomy,  ar- 
tificial anus, 
three      days 
later     resec- 
tion of  bowel 

Ibid. 

Dent 

Band     (probably 

3     „ 

Laparotomy 

Brit.    Med.   Journ. 

stretched  pen- 

and  division 

1894,  i.  118 

to  iieal       adhe- 

of baud 

sion) 

Tldery 

Band  (fibrous) 

Not  given 

" 

Ann.  Univ.  Med.  Sci. 
1894,  iii.  C— 23 

364  THE   JEJUNUM   AND   ILEUM 

Table  of  Successful  Operations  dc.  (continued) 


Operator 

Nature  of  Con- 
stiictiou 

Time  intervening 

between  onset  of 

symptoms  and 

operation 

Nature  of 
Operation 

Eoference 

L.  Smith  . 

J.  H.  Braham  . 

H.  Thompson  . 

A.  H.  Cordier  . 
J.  Murphy 

Pick 

Ha-ward   . 

„  (2iid  case) 

Band     (attached 
by  one  end  to 
the  large  intes- 
tine,    by     tlie 
other     to     the 
small) 

Band  (extending 
from        broad 
ligament       to 
cffical  region) 

Baud  (extending 
from   one  part 
of     mesentery 
to  another) 

Band 

Band 

Meckel's  diverti- 
culum        and 
another  band 

2  or  3  bauds 

Band 

Not  given 

4  days 

9     „ 

Not  given 
Not  given 

3  days 

3     „ 
3    „ 

Laparotomy 
and    separa- 
tion of  band 

Laparotomy 
and  division 
of  band 

Eesection       of 
4     inches  of 
bowel,    end- 
to-end     ana- 
stomosis 
with      Mur- 
phy's button 

Laparotomy 

Ann.  Univ.  Med.  Sci. 
1894,  iii.  C— 24 

Annals  of  Siirgery, 

1894,  XX.  50 

Lancet,  1894,  ii.  382 

Ibid.  1895,  i.  1042 
Ibid. 

Brit.    Med.   Journ. 

1895,  ii.      126. 
Ho'iints's  tables 

JMd. 
JUd. 

Column  2  contains,  where  stated  in  the  report  of  the  case, 
the  nature  of  the  agent  producing  the  obstruction.  In  many 
cases  it  is  definitely  stated  that  it  "was  either  not  possible  or 
not  deemed  advisable  to  prolong  the  operation  in  order  to 
search  for  the  exact  attachment  of  the  constricting  agent, 
"whether  a  band,  an  aperture,  or  hernial  fossa. 

Column  3  gives  the  time  at  "which  the  operation  "was  per- 
formed after  the  onset  of  .the  symptoms.  The  earliest  date 
given  is  fifteen  hours,  and  the  latest  t"welve  days.  It  is 
probable  that  at  no  period  of  the  disease  is  the  operation 
forbidden,  unless  the  patient  be  moribund.  Where  fsecal 
vomiting  "was  stated  in  the  report  to  be  present  at  the  time 
of  operation,  it  has  been  noted ;  and  it  is  interesting  to  see 
in  how  many  cases  this  advanced  symptom  existed. 

Column  4  indicates  the  nature  of  the  operation  performed. 
In  almost  every  instance  of  constriction  by  a  band,  this  was 
either  simply  divided,  or  lioatured  in  two  places  and  divided 
between.  In  cases  where  the  vermiform  appendix  or  Meckel's 
diverticulum  proved  to  be  the  constricting  band,  care  was 


INTERNAL    HERNIA    UNDER   BANDS   ETC.  3G5 

taken  to  close  the  patent  orifice,  if  such  existed.  In  only 
one  case  (Dorfler)  was  it  found  necessary  to  form  an  arti- 
ficial anus.  Three  days  later  fifteen  centimeters  of  the  gut 
were  resected,  and  the  patient  recovered.  The  author 
states  that  the  bowel  had  become  gangrenous  in  twenty-eight 
hours. 

The  inevitably  fatal  result  which  follows  in  this  class  of 
cases  when  left  alone,  and  the  success  which  has  attended 
surgical  intervention,  may  be  taken  as  am])le  justification 
for  operation.  And,  further,  the  rapidity  with  which  gangrene 
occurs  in  cases  of  a  tense  constricting  band  renders  early 
operation  imperative. 

Laparotomy  should  be  performed  in  the  usual  way  by  a 
median  incision  below  the  umbilicus,  the  opening  being 
enlarged  as  required.  In  many  instances  the  band  will  give 
way  during  the  process  of  manipulation,  in  other  cases  it 
must  be  divided ;  and  when  vascular  or  formed  of  some 
normal  structure  abnormally  attached,  care  must  be  taken  to 
efficiently  ligature  or  close  the  parts. 

If  the  bowel  be  not  gangrenous,  the  result  of  relieving  the 
constriction  will  be  to  cause  it  to  resume  rapidly  a  more  natural 
appearance,  the  lividity  of  its  walls  giving  place  to  a  pinker 
colorisation,  and  the  distension  of  the  gut  above  subsiding, 
M'hile  at  a  not  distant  period  flatus  and  fseces  will  pass  from 
the  rectum. 

Should  the  bowel  be  gangrenous,  the  surgeon  must  decide 
from  the  condition  of  the  patient  whether  he  should  adopt 
the  more  rapid  method  of  forming  an  artificial  anus,  subse- 
quently dealing  with  the  part,  or  whether  he  should  at  once 
remove  the  gangrenous  portion  and  form  a  lateral  or  end-to- 
end  anastomosis.  With  Murphy's  button  less  time  might  be 
spent  in  uniting  the  bowel  end  to  end  after  removal  than 
in  making  an  artificial  anus.  In  his  records  of  cases  in 
which  the  button  has  been  used.  Murphy  '  quotes  two  suc- 
cessfully so  treated.  Failing,  however,  such  a  ready  means, 
and  the  patient's  strength  appearing  unequal  to  a  prolongtd 
operation,  the  distended  part  of  the  gut  above  should  be 
stitched  to  the  wound,  and  an  artificial  anus  established. 

'  hancd,  1895,  vol.  i.  p.  10-12. 


366  THE   JEJUNUM   AND   ILEUM 

In  cases  where  faecal  vomiting  has  set  in,  much  relief  is 
obtained  by  washing  out  the  stomach. 

After  treatment. — In  all  cases  where  the  bowel  has  been 
efficiently  liberated,  fluid  diet  may  be  commenced  at  once. 
For  the  first  few  days  small  quantities  of  opium  should  be 
given,  and  the  diet  should  not  be  too  plentiful.  The  bowels 
are  likely  to  act  freely.  In  order  to  obtain  a  secure  cicatrix 
in  the  parietal  wound,  the  patient  should  not  be  allowed  up 
for  about  three  weeks. 

Case  LXXV. — Intestinal  obstruction  due  to  the  occlusion  of  the  ileum 
by  a  band  :  ojperation.     Recovery. 

A  girl  aged  14  years  had  for  the  last  fonr  years  been  subject  to  what 
were  called  bilious  attacks,  the  prominent  symptom  of  which  was  vomit- 
ing, which  lasted  for  one  or  two  days  and  was  often  accompanied  by  pain 
and  sometimes  by  diarrhoea.  For  twelve  months  she  had  had  consider- 
able pain  in  the  epigastrium,  which  came  on  directly  after  taking  food,  and 
often  resulted  in  sickness.  About  two  years  back  she  suffered  great  pain 
in  the  right  side  on  exertion,  more  particularly  if  the  attempted  to  walk 
quickly  or  to  run. 

On  Decemb  r  7,  1893,  while  at  her  work,  she  was  suddenly  seized 
with  violent  pains  shooting  across  the  abdomen  in  the  line  of  the  umbili- 
cus. She  vomited  several  times  on  her  way  home,  and  on  her  arrival 
went  to  bed.  The  acute  symptoms  abated  somewhat.  For  two  or  three 
days  she  remained  in  considerable  pain  with  occasional  sickness,  when 
her  mother  administered  a  copious  soap-and-water  enema.  This  gave 
temporary  relief  by  emptying  the  large  bowel  of  gas,  but  the  pain  and 
vomiting  returned  with  renewed  severity.  On  December  13  the  patient 
was  in  great  pain,  with  moderate  distension,  good  pulse,  moist  tongue, 
and  normal  temperature.  On  December  15,  eight  days  after  the  onset, 
the  vomiting  became  fsecal.  On  December  19,  when  first  seen  by  the 
author,  she  prepented  symptoms  of  collapse — a  small  quick  pulse,  dry 
tongue,  haggard  look,  listless  demeanour,  and  rapid  shallow  respirations. 
The  abdomen  was  distended  and  tympanitic,  especially  round  the  middle 
line.  Feculent  material  was  being  vomited  every  few  minutes,  thirst 
was  intense,  and  there  was  pain  on  pressure  over  the  right  side  of  the 
abdomen.  The  patient  was  mentally  alert,  and  took  an  intelligent  inte- 
rest in  her  affairs. 

Laparotomy  was  performed  on  December  19,  twelve  days  after  the 
onset  of  symptoms.  A  band  about  half  an  inch  broad  was  found  stretch- 
ing apparently  transversely  across  the  gut  from  the  direction  of  the  right 
kidney.  Ligatures  were  applied  and  the  strand  severed.  Peritonitis 
had  set  in,  as  evidenced  by  the  adherent  condition  of  the  coils.  The 
operation  occupied  twenty  minutes.  The  patient  made  an  uninterrupted 
recovery.     (Robert  Jones,  '  Brit.  Med.  Journ.'  1894,  vol.  i.  p.  1123.) 


INTERNAL   HERNIA    UNDER   IJANUS   ETC.  3G7 


Cask  LXXVI. — Acute  intestinal  ohstruction  jprodnced  hij  Meckel's 
diverticulum.     Death. 

James  C,  .iged  4  years,  while  enjoying  good  heaHli,  was  suddenly 
seized  with  acute  pain  in  the  abdomen  on  January  18,  1895.  He  shortly 
afterwards  vomited,  and  the  pain  continuing  to  increase,  his  parents 
gave  him  some  hot  brandy  and  water,  and  applied  hot  fomentations  to  his 
belly.  On  January  21 — three  days  after  the  onset  of  his  symptoms — he 
was  admitted  into  the  Victoria  Infirmary.  His  face  was  pale,  with  dark 
depressions  beneath  the  eyes.  He  was  drowsy,  and  when  roused  com- 
plained greatly  of  thirst.  Everything  taken  was  vomited.  His  pulse  was 
full,  easily  compressible,  and  about  seventy  p?r  minute.  The  abdomen  was 
tumid  and  swollen,  tympanitic  in  the  upper  part,  but  dull  and  somewhat 
resistant  below.  By  palpation  nothing  of  the  nature  of  a  tumour  could 
be  felt,  and  manipulation  of  the  belly  did  not  cause  pain.  Rectal  exami- 
nation revealed  nothing,  but  on  withdrawal  of  the  finger  a  little  blood 
was  detected  upon  its  apex.  The  respiration  was  chiefly  thoracic  and 
somewhat  laboured.  The  parents  stated  that  nothing  had  come  by  the 
bowel  except  some  blood  which  followed  the  injection  of  water  on  the 
morning  of  the  day  of  admission. 

The  diagnosis  made  was  thqt  of  probable  intussusception,  and  the 
collapsed  condition,  as  well  as  the  age  of  the  child,  rendered  operation 
inadvisable.  The  next  morning  there  was  faecal  vomiting,  and  in  the 
evening  the  child  died. 

Post  mortein. — The  distended  coils  of  intestine  were  slightly  glued 
together,  giving  evidence  of  peritonitis.  The  whole  of  the  large  intes- 
tine and  about  four  inches  of  the  ileum  at  its  caecal  extremity  were 
collapsed.  About  twelve  inches  of  the  ileum  above  this  were  also  col- 
lapsed, and  constituted  a  loop  which  had  passed  beneath  a  constricting 
band,  comprised  of  Meckel's  diverticulum  about  an  inch  and  a  half  in 
length  and  a  fibrous  cord  an  inch  long,  extending  from  its  apex  and 
attached  to  some  enlarged  mesenteric  glands.  The  remaining  part  of 
the  ileum  and  the  jejunum  were  greatly  distended,  containing  a  con- 
siderable quantity  of  yellow  watery  faecal  matter.  The  diverticulmn 
communicated  with  the  ileum  by  a  small  orifice  ;  from  this  point  onwards 
the  canal  enlarged,  and  formed  a  sac  somewhat  egg-shaped.  It  had  become 
gangrenous,  but  no  perforation  had  taken  place.  The  coil  of  gut  which 
had  passed  beneath  the  bridge  of  diverticulum  and  band  could  be  easily 
withdrawn,  and  did  not  seem  to  have  been  acutely  strangulated. 
(A.  Ernest  Maylard,  Clinical  Reports,  1895.) 

It  is  impossible  not  to  feel,  in  this  latter  ease,  that  an 
operation  performed  ^Yithin  twelve  hours  of  the  onset  of 
the  symptoms  would  have  been  fraught  with  success.  By  the 
simplest  manipulation  the  loop  could  have  been  disengaged, 
and  by  a  very  simple  extension  of  the  operation  the  diverti- 
culum and  band  could  have  been  removed      Had  I  but  known 


368  THE   JEJUNUM   AND   ILEUM 

also  the  real  nature  of  the  ohstructing  agent,  I  think  I  should 
have  been  tempted,  notwithstanding  the  age  and  condition  of 
the  child,  to  have  made  an  exploratory  incision  shortly  after 
admission. 


CPIAPTEE   XLIII 

2.    ADHESIONS.      KINKING 


There  is  a  large  class  of  cases  where  obstruction  of  both  an 
acute  and  chronic  character  arises  from  adhesions  which  do 
not  necessarily  form  well-defined  bands.  The  function  of  the 
bowel  in  this  class  of  cases  becomes  impaired  by  reason 
either  of  the  altered  position  it  is  caused  to  assume  by  being 
dragged  up  or  down  or  fixed,  or  by  the  contraction  of  ad- 
hesions constricting  it  or  causing  it  to  be  kinked.  In  some 
cases  it  is  only  a  limited  portion  of  the  bowel  which  is  involved, 
while  in  others  the  intestines  are  extensively  matted  together. 

While  the  immediate  cause  of  these  adhesions  is  some 
antecedent  local  or  general  peritonitis,  they  are  indirectly  the 
result  of  inflammation  connected  with  injury  or  disease. 
Thus  tubercular  peritonitis  is  a  fruitful  source  of  extensive 
general  adhesions,  while  operations  which  involve  opening 
the  peritoneal  cavity  are  more  commonly  the  cause  of  local 
matting. 

Considerable  interest  attaches  to  this  latter  class,  from 
the  frequency  with  which  abdominal  operations  are  now  per- 
formed. Quite  a  number  of  cases  have  been  recorded  illus- 
trative of  serious  obstructive  troubles  arising  from  the  for- 
mation of  post-operative  adhesions.  Lucas-Championniere  ' 
records  five  cases  where  symptoms  of  obstruction  set  in  a 
few  days  after  operation.  In  one  the  operation  was  for  the 
removal  of  an  ovarian  tumour,  in  another  for  the  relief  of  a 
strangulated  hernia,  and  in  three  others  for  the  radical  cure 
of  hernia.  Eohe^  has  collected  no  fewer  than  seventy-five 
deaths  from  acute  intestinal  obstruction  following  upon  in- 
traperitoneal operations.      He  states  that  obstruction  of  the 

'  Revue  cle  Chirurgie,  1892,  p.  264. 

^  Annals  of  Surgenj,  1895,  vol.  xxi.  p.  104. 


ADHESIONS.      KINKING  369 

bowel  causes  between  one  and  two  per  cent,  of  tbe  deaths 
following  ovariotomy  and  other  such  like  operations.  Harrison 
Cripps '  has  published  a  case  where  acute  obstruction  set  in 
eighteen  days  after  the  removal  of  a  large  multinodular  fibroid 
growing  beneath  the  broad  ligament.  The  adhesions  proved 
so  inseparable  from  the  bowel  that  the  damage  inflicted  upon 
the  latter  necessitated  the  formation  of  an  artificial  anus. 
This  was  afterwards  successfully  dealt  with  by  excision,  and 
end-to-end  anastomosis  effected. 

In  by  far  the  larger  proportion  of  cases  the  cause  of 
obstruction  is  due  either  to  adhesions  of  coils  of  intestine  to 
one  another,  or  of  these  to  the  abdominal  wall  or  to  other 
viscera.  Jones  ^  records  a  case  of  adhesion  at  the  neck  of  an 
old  femoral  hernia.  He  also  narrates  two  other  cases,  one 
where  the  adhesions  were  connected  with  an  old  appendicitis, 
and  one  where  they  were  found  at  the  posterior  wall  of  the 
abdomen.  Fowler  ^  records  a  case  of  intestinal  obstruction 
due  to  adhesions  the  result  of  an  appendicectomy  performed 
three  weeks  before ;  and  another,  where,  as  the  result  of  some 
past  intrapelvic  inflammation,  the  small  intestines  were  found 
bound  down  by  old  adhesions  in  the  pelvis  and  just  behind 
the  cfficum.  A  case  similar  to  this  last  is  recorded  by  West 
and  Littlewood,^  where  a  coil  of  intestine  was  bound  down  to 
the  rectum;  the  acute  obstruction  was  relieved  by  separating 
the  adhesions,  and  the  patient  recovered.  Cave  ■''  mentions  a 
case  where  adhesions  the  result  of  a  healed  tubercular 
peritonitis  had  led  to  kinking  of  the  bowel.  A  somewhat 
similar  case  of  kinking,  the  result  of  a  local  peritonitis,  is 
recorded  by  Paul.'^ 

Symptoms. — Obstructive  symptoms  may  arise  in  one  of 
two  ways,  either  acutely  and  suddenly,  or  slowly  with  such 
indications  as  colicky  pains,  constipation,  occasional  vomiting, 
and  other  vague  feelings  of  abdominal  discomfort.  In  those 
cases  where  the  symptoms  occur  at  an  interval  after  an  attack 
of  inflammation  connected  with  some  internal  viscus  or  with 
peritonitis,  local  or  general,  some  clue  is  obtained  as  to  the 

'  Brit.  Med.  Journ.  1894,  vol.  ii.  p.  1103. 

-  Lancet,  1891,  vol.  i.  p.  1370. 

'  Annals  of  Surgery,  1894,  vol.  xix.  pp.  165,  3.59. 

'  Brit.  Med.  Journ.  1S96,  vol.  i.  p.  1330. 

■'*  Ihid.  1894,  vol.  ii.  p.  fi7.  '  Lancet,  1894,  vol.  i.  p.  609. 


370  THE   JEJUNUM   AND   ILEUM 

possible  cause  of  the  obstruction  ;  but  in  many  of  the  post- 
operative cases,  more  particularly  in  those  occurring  within  a 
comparatively  shorl;  time  of  the  operation,  the  symptoms 
may  be  marked  by  pain,  vomiting,  and  tympanites,  results  as 
much  likely  to  be  due  to  the  operation  itself  as  to  any  in- 
testinal mischief  directly  dependent  upon  it. 

It  is  more  usual,  however,  for  an  interval  of  some  days  to 
elapse  before  any  obstructive  symptoms  manifest  themselves. 
In  any  case,  therefore,  where  a  patient  is  suddenly  seized 
with  acute  pain  accompanied  with  obstinate  vomiting,  sym- 
ptoms which  show  no  sign  of  abatement,  and  to  which  are 
added  some  tympanites  and  inability  to  pass  faeces  and  flatus, 
suspicions  should  be  entertained  that  the  bowel  has  become 
obstructed  in  some  way  by  adhesions. 

In  cases  of  obstruction  occurring  only  a  few  days  after 
operation,  the  adhesions  are  usually  soft,  of  the  nature  of 
lymph,  and  easily  detached. 

Treatment. — From  the  nature  of  the  obstructing  agent, 
nothing  but  operation  can  be  of  any  avail.  When  taken  suffi- 
ciently early,  before  the  patient  begins  to  show  any  serious 
constitutional  symptoms,  success  may  be  reasonably  expected 
after  laparotomy  and  separation  of  the  adhesions.  The  cases 
above  alluded  to,  recorded  by  Lucas-Championniere,  Jones, 
Cave,  and  Paul,  were  all  successful. 

When  symptoms  of  obstruction  manifest  themselves  after 
ovariotomy  or  other  intraperitoneal  operations,  no  delay 
should  be  exercised  in  reopening  the  wound  or,  if  deemed 
advisable,  employing  a  fresh  incision.  When  the  adhesions 
cannot  bo  separated  without  serious  injury  to  the  bowel,  it 
will  be  necessary  to  remove  the  involved  portion,  or  perform 
lateral  anastomosis  where  the  coils  are  free.  Murphy  ^  quotes 
four  cases  where  one  or  other  of  these  measures  was  success- 
fully carried  out.  In  a  case  of  my  own,  the  vermiform 
appendix  had  such  firm  adhesions  to  the  neighbouring  part 
of  the  ileum  that  in  endeavouring  to  sever  them  I  tore 
the  bowel  and  was  obliged  to  excise  about  three  inches. 
The  parts  were  joined  by  end-to-end  anastomosis,  and  the 
patient  made  an  uninterrupted  recovery.  ■  A  similar  accident 
happened  in   Cripps's  case  already  quoted ;    the   treatment, 

'  Lancet,  1895,  vol.  i.  p.  1042. 


INTUSSUSCEPTION  371 

however,  differed  in  this  respect,  that  in  the  latter  case 
an  artificial  anus  was  first  established,  and  subsequently 
excision  was  performed. 

Case  LXXVII. — Acute  intestinal  obstruction  from  constricting  adhesions 
the  result  of  repeated  attaclis  of  apjiendicitis. 

A  man  aged  35  years  had  suffered  from  attacks  of  peritonitis  for  some 
3'ears.  Thirteen  days  before  the  operation  he  was  seized  with  sudden 
acute  griping  pain  in  the  abdomen,  the  attack  lasting  about  an  hour  and 
then  passing  off.  Similar  attacks  occurred  at  varying  but  frequent 
intervals,  the  bowels  being,  however,  open,  though  imperfectly.  Thirty- 
six  hours  before  the  operation  he  took  a  dose  of  castor  oil,  which  set  up 
intense  pain,  and  was  followed  by  complete  obstruction,  and  about  twenty 
hours  afterwards  by  extreme  coUapse.  About  thirty  hours  after  the  castor 
oil  he  had  faecal  vomiting,  and  when  put  on  the  table  he  was  practically 
moribund  and  his  pulse  could  not  be  felt. 

The  abdomen  was  opened,  the  appendix  which  encircled  the  ileo-caecal 
valve  removed,  and  the  adhesion  cut  and  torn  through  till  the  contents  of 
the  small  intestine  could  be  readily  squeezed  into  the  large.  The  patient 
lay  in  an  almost  pulseless  condition  for  thirty  hours  after  the  operation, 
without  vomiting,  however,  and  without  any  marked  pain,  and  then  he 
had  two  copious  and  very  offensive  stools.  After  that  he  was  very  col- 
lapsed, but  soon  recovered,  and  when  seen  thirty-six  hours  after  the 
operation  his  pulse  had  greatly  improved.  His  subsequent  recovery 
was  uninterrupted.  (Watson  Cheyne,  '  Brit.  Med.  Journ.'  1894,  vol.  i. 
p.  9G7.) 


CHAPTEE   XLIV 

3.    INTUSSUSCEPTION 


The  passage  of  one  segment  of  the  bowel  into  another  may 
take  place  at  any  point,  implicating  either  the  small  intestine 
alone,  or  the  small  and  the  large  together,  or  only  the  large. 
By  far  the  largest  number  of  cases  are  those  where  both  large 
and  small  are  involved. 

It  is  usual  to  classify  these  various  kinds  of  intussuscep- 
tion into  enteric,  ileo-ccecal,  ileo-coUc,  colic,  and  rectal.  Only  the 
first  three  will  be  described  here,  the  latter  being  discussed 
under  Affections  of  the  Large  Bowel. 

In  order  of  frequency  the  ileo-csecal  stands  first,  the  ileo- 
colic is  least  often  met  with,  and  the  enteric  occupies  an 
intermediate  position. 

B   B    2 


372  THE   JEJUNUM   AND   ILEUM 

Obstruction  from  intussusception  is  much  more  common 
during  the  early  years  of  Hfe.  At  this  period  it  is  usually  of 
the  acute  and  complete  form,  but  when  occurring  in  later  years, 
it  is  often  chronic  and  incomplete. 

Pathological,  anatomy. — The  form  of  intussusception  which 
gives  rise  to  obstruction  during  life,  as  contrasted  with  that 
which  is  so  frequently  found  after  death,  a.nd  which  is  probably 
produced  immediately  prior  to  the  extinction  of  life,  is  almost 
without  exception  single,  and  the  result  of  an  upper  section 
of  the  bowel  passing  into  the  section  immediately  below. 

In  the  ileo-ccecal  variety  a  prolapse  of  the  ileo-ctecal 
valve  takes  place  into  the  csecum,  and  to  whatever  extent  the 
invagination  proceeds,  the  valve  always  forms  the  apex  or 
presenting  part. 

In  the  enteyic  variety  a  portion  of  the  small  intestine  slips 
into  a  section  of  the  same  immediately  below.  This  may 
occur  in  any  part  of  the  jejunum  or  the  ileum. 

In  the  ileo-colic  the  ileum,  at  its  lower  part,  first  passes 
into  a  section  of  its  own  immediately  below,  and  then  proceed- 
ing, passes  through  the  ileo-csecal  valve  into  the  caecum  and 
colon,  so  that  the  apex  or  presenting  part  is  always  a  part  of 
the  ileum.  When  this  variety  extends  for  any  distance  down 
the  colon,  it  is  frequently  at  the  expense  of  the  csecum  and 
ascending  colon. 

If  a  transverse  section  be  carried  through  a  simple  intus- 
susception, it  will  be  found  that  between  the  central  lumen  of 
the  bowel  and  the  exterior  there  are  three  layers  of  gut  wall. 
The  external  one  is  termed  the  sheath  or  intussuscipiens,  the 
internal  the  entering  layer,  and  the  middle  the  returning  layer. 
The  two  latter  combined  constitute  the  intussusceptum  (see  fig. 
51).  It  will  therefore  be  seen  that  the  opposing  surfaces  of 
the  external  and  middle  layers  are  formed  by  the  mucous 
lining  of  the  bowel,  while  the  opposing  surfaces  of  the  middle 
and  internal  are  formed  by  the  serous  or  peritoneal  coat. 
Between  these  two  latter  exists  the  mesentery.  The  present- 
ing part  of  the  intussusceptum  is  called  the  ajyex,  while  the 
point  of  junction  of  the  intussusceptum  with  the  intussus- 
cipiens constitutes  the  neck.  A  reference  to  the  accompanying 
diagram  will  show  the  parts  designated. 

In   some  rarer  instances  the   intussusception   is   double, 


INTUSSUSCEPTION 


373 


5-- 


vn^ 


^ 


and  still  more  rare  is  the  occurrence  of  the  triple  variety. 
In  the  case  of  the  douhle  kind,  a  transverse  section  would  re- 
veal two  extra  layers,  that  is  to  say,  five  in  place  of  three  ; 
while  in  the  triple  form  there  would  he  seven  layers. 

In  length  the  enteric  form  is  usually  shorter  than  the 
others.  All  increase  in  length  is  at  the  expense  of  the  sheath 
or  intussuscipiens,  except  in  the 
case  of  the  ileo-colic,  where  for 
the  earlier  stage  of  its  course  it  is 
the  entering  layer  which  continues 
to  pass  in.  The  length  of  the 
intussusception  is  probably  deter- 
mined by  the  length  of  the  mesen- 
tery and  the  quantity  of  fat  it 
contains.  A  congenitally  short 
mesentery  or  one  which  contains 
much  fat  will  materially  impede 
any  very  extensive  process  of  in- 
vagination. 

While  the  mesentery  has  to 
some  extent  an  inhibitory  effect 
upon  the  progress  of  the  intussus- 
ceptum,  it  has  also  the  effect  of 
altering  its  course  and  causing 
pressure  upon  the  neck.    Attached      '2    *  '     i    a 

to  one  side  only  of  the  bowel,  it  p^^_  si.-Diagram  0.  LoNaixuDi- 
draws  upon  that  side  and  more 
particularly  upon  the  apex.  Hence 

tllP  IniTlpn  nf  i-lnp  laf+pv  iq  mcirlp  1,  peritoneum ;  2,  muscle  coat ;  3,  mucous 
lUe    lUmen     OI    me    laiiei     is    maae        membrane  ;  a,  apex  of  intussusceptum  ; 

to  Innk  to  nno  cnVlp  nnrl  iho  6,  neck  of  intussusception;  c,  enterius 
lO      lOOK      10      one     Sme,     ana      ine        layer ;  rf,  returning  layer ;  c  and  d  conv 

mesenteric  border  assumes  a  con-     or'IftusLTsctlelfs'''''''''^*™ 
cavity  with  a  corresponding  con- 
vexity on  the  opposite   aspect.      Further,  this  traction,    as 
the  invagination  increases,  renders  the  intussusceptum  liable 
to  become  twisted  within  the  sheath. 

If  the  mesentery  were  removed  from  the  intussusceptum, 
divided  at  the  neck,  and  spread  out,  it  would  be  found  to  be 
triangular  in  shape  ;  the  apex  of  the  triangle  would  represent 
the  part  at  the  apex  of  the  intussusceptum,  while  the  base 
would  correspond  to  its  neck.      Hence  it  will  be  obi-erved  that 


NAjj    Section   of   an 

CEPTION 


Intussus- 


374  THE   JEJUNUM   AND   ILEUM 

much  more  is  contained  within  the  sheath  at  the  proximal  end 
of  the  intussusception  than  at  the  distal.  The  effect  of  this 
and  the  other  points  given  above  upon  the  causation  of  acute 
obstruction  will  now  be  described. 


Fig.  53.— Ileo-c^cal  Intussusception  (Coats) 

The  colon  is  laid  open  and  several  coils  of  ileum  are  shown  which  have  protruded  through  the 
ileo-ca3cal  valve.     One  of  the  coils  was  gangrenous. 

The  indirect  and  direct  causes  of  obstruction. — In  discussing 
the  various  causes  which  bring  about  intestinal  obstruction 
connected  with  intussusception,  it  is  found  that  they  group 
themselves  under  two  more  or  less  distinct  heads.  First,  there 
are  those  which  are  remote  or  indirect  in  their  effect,  and, 
second,  those  which  are  immediate  or  direct. 

Indirect  or  remote. — These  causes  are  connected  with  the 
primary  formation  of  the  intussusception.  "While  in  many 
cases  it  does  not  seem  possible  to  fix  upon  any  particular 
agent  as  the  initial  incentive  to  invagination,  there  are  not  a 
few  in  which  it  is  traceable  either  to  mechanical  obstruction 
within  the  bowel  or  to  the  effect  of  some  irregular  innervation 
of  the  involuntary  muscle  tissue  forming  one  of  its  coats. 

The  commonest  form  of  an  obstructive  cause  is  found  in 
tumours,  such  as  polypi,  attached  to  the  mucous  membrane. 
They  usually  appeal-  at  the  apex  of  the  intussusceptum,  and 


INTUSSUSCEPTION  .'JZo 

thus  suggest  the  probable  action  they  take  in  starting  an 
invagination  by  suddenly  dragging  in  a  section  of  the  intes- 
tinal wall.  The  fact,  however,  that  polypi  are  not  constant 
in  this  position  militates  against  so  simple  a  mechanical 
view.  Lockwood '  reports  a  case  where  the  polypus  was 
situated  above  the  apex. 

Another  form  of  obstruction  is  possibly  to  be  found  in  the 
constricted  orifice  of  the  ileo-caecal  valve,  which,  under  certain 
conditions  of  the  contents  of  the  ileum,  may  be  prolapsed  into 
the  csecum. 

That  irregular  innervation  of  the  muscular  coat  plays  a  not 
unimportant  part  in  causing  intussusception  appears  likely 
from  the  experiments  performed  by  Nothnagel  on  rabbits, 
quoted  by  Treves.-  These  experiments  went  to  show  that  a 
localised  stimulation  of  the  bowel  by  electricity  brought  about 
a  contraction  which  ended  in  the  formation  of  an  intus- 
susception. It  is  not  difficult  to  take  a  step  further  in  a 
clinical  direction  and  assume  that  certain  stimulants  lead 
to  a  similar  localised  contraction,  with  resulting  invagination. 
Whether  these  stimulants  act  from  a  distance  through  the 
nervous  system,  or  more  directly  upon  the  mucous  membrane 
of  the  bowel,  it  may  not  be  always  easy  to  determine.  But 
from  the  clinical  history  often  obtainable  it  would  seem 
that  in  not  a  few  cases  gastro-intestinal  disturbances  have 
been  caused  by  the  ingestion  of  such  irritants  as  unripe  fruit 
and  other  indigestible  substances. 

The  fact  that  in  many  cases  the  patients  are  out  of  health 
or  debilitated  would  point  to  the  possibility  of  there  being 
some  want  of  tone  in  the  muscle  tunic,  and  consequently 
imperfect  innervation  and  irregular  peristaltic  action.  When 
once  the  invagination  has  taken  place,  its  further  progress  is 
probably  brought  about  by  the  bowel  above  tending  to  force 
it  on. 

The  direct  or  immediate  cause  of  ohstruction. — The  invagi- 
nation of  any  portion  of  the  bowel  does  not  necessarily  give 
rise  to  obstruction  at  once.  The  lumen  of  the  internal 
cylinder  may  remain  sufficiently  patent  to  admit  of  the  bowel 
contents  passing ;  it  is  only  when  from  some  cause  this  cy- 
linder becomes  partially  or  completely  occluded  that  symptoms 

'   Trans.  Path.  Soc.  Lond.  1892,  vol.  xliii.  p.  74.  -  Pago  204. 


376  THE   JEJUNUM   AND   ILEUxU 

of  obstruction  become  manifest.  It  will  thus  be  seen  that 
three  conditions  are  possible  :  one,  where  no  obvious  obstruc- 
tion exists  ;  two,  where  it  is  partial ;  and  three,  complete. 

The  changes  which  take  place  in  the  part,  and  which  are 
now  to  be  described,  will  serve  to  more  fully  explain  these 
conditions,  as  well  as  afford  elucidation  of  the  difficulties 
which  the  surgeon  has  to  encounter  in  his  treatment  of 
them. 

Immediately  an  intussusception  is  formed,  pressure  com- 
mences to  be  brought  to  bear  upon  the  base  of  the  triangular- 
shaped  piece  of  mesentery  at  the  neck  of  the  tumour.  Inas- 
much as  this  contains  both  the  arteries  and  the  veins  of  the 
intussusceptum,  the  effect  of  the  pressure  is  first  to  obstruct 
the  veins,  and  hence  impede  the  return  of  blood  from  the 
part.  Should  this  pressure  only  be  slight,  no  further  changes 
of  an  acute  character  need  take  place  ;  and,  failing  any  natural 
reduction,  the  remoter  processes  may  consist  in  some  organic 
union  of  the  parts  so  that  no  further  obstruction  occurs.  In 
some  cases  the  intussusceptum  will  be  gradually  cast  off, 
either  entire  or  in  irregular  shreddy  pieces. 

Assuming,  however,  that  the  effect  of  pressure  on  the  veins 
is  sufficient  to  lead  to  further  and  more  serious  changes,  it 
win  be  found  that  these  changes  consist  in  a  gradual  engorge- 
ment of  the  coats  of  the  intussusceptum.  The  part  to  be  first 
affected  will  be  the  apex,  then  the  middle  layer,  mostly  on  its 
convex  aspect,  and  lastly  the  mesentery  itself.  The  combined 
effect  of  these  two  latter  influences  will  be  to  produce  pressure 
at  the  neck  sufficient  to  obstruct  the  arteries.  Hence,  with 
the  blood  supply  entirely  cut  off,  gangrene  of  the  intussuscep- 
tum will  follow.  The  engorgement  of  the  coats,  besides  leading 
to  external  oedema  and  consequent  swelling,  causes  rupture  so 
that  blood  escapes  into  the  bowel  beyond.  Another  result  of 
this  venous  congestion  or  of  later  ulceration  is  the  occasional 
formation  of  adhesions  between  the  internal  and  middle 
layers — that  is,  between  the  two  opposed  serous  surfaces.  The 
changes  effected  in  the  sheath  or  intussuscipiens  are  usually 
slight ;  when  much  pressure  is  brought  to  bear  upon  its 
mucous  lining  owing  to  the  size  of  the  intussusceptum,  some 
ulceration  and  even  sloughing  may  result. 

Considering   the   changes   thus   brought   about,  together 


PLATE    XVII. 


Fig.  52.— Ileo-c/ecal  Intussusception. — The  apex  of  the  intussusceptum  is  seen 
through  the  aperture  below.  Above,  the  sheath,  or  intussuscipiens,  is  cut 
away  to  show  the  two  layers — the  entering  and  returning — of  the  intus- 
susceptum.    (R.I.M.,  Glas.) 


INTUSSUSCEPTIOxX  377 

with  the  part  played  by  the  mesentery  in  its  traction  upon 
the  bowel,  it  is  not  difficult  to  understand  how  complete 
obstruction  is  effected.  The  block  may  exist  either  at  the 
neck,  in  the  body,  or  at  the  apex  of  the  intussusceptum. 
"When  occurring  at  the  neck,  it  is  due  to  the  pressure  exercised 
by  the  mass  of  mesentery  which  has  been  dragged  in,  plus  the 
engorgement  of  the  middle  cylinder  from  venous  congestion. 
When  the  block  occurs  in  the  body  of  tlie  intussusceptum, 
it  is  from  torsion  of  the  part,  effected  by  the  mesenteric 
attachment ;  and  when  occurring  at  the  apex,  it  may  be  due 
to  the  occluding  effect  of  greater  engorgement  of  this  part, 
together  with  the  tilted  and  narrowed  orifice  effected  again  by 
traction  of  the  mesentery.  It  will  thus  be  seen  that,  at  what- 
ever point  obstruction  takes  place,  the  principal  agent  in  pro- 
ducing it  is  the  mesentery. 

Obstruction,  however,  may  be  brought  about  suddenly  in 
cases  where  the  changes  above  described  are  not  in  them- 
selves acute.  Three  cases  have  been  recorded  where  it  was 
found  that  the  internal  cylinder  had  become  obstructed  by 
some  indigestible  material  which,  while  capable  of  passing  quite 
easily  through  the  normal  canal,  could  not  get  transmitted 
through  the  reduced  lumen  of  the  intussusceptum. 

There  are  certain  points  of  practical  surgical  interest  in 
connection  with  these  changes  which  are  worthy  of  note. 

First  as  regards  the  formation  of  adhesions  between  the 
middle  or  returning  layer  and  the  entering  layer.  What- 
ever may  be  their  actual  cause,  there  are  considerable  diffi- 
culties as  regards  their  date  of  appearance,  when  reckoned 
from  the  onset  of  the  symptoms.  Thus,  in  a  case  recorded  by 
Marsh,^  laparotomy  was  performed  fifteen  hours  after  the 
onset  of  symptoms,  and  yet  in  this  comparatively  short  time 
adhesions  had  formed  so  firmly  between  the  opposing  serous 
layers  that  reduction  was  impossible.  Makins  ^  also  records  a 
case  where,  at  the  post  mortem,  tight  adhesions  existed,  although 
death  occurred  forty-eight  hours  after  the  onset  of  symptoms. 
On  the  other  hand,  Baur,^  in  an  exhaustive  discussion  upon 
the  subject,   states  that  adhesions  may  not  take  place  for 

'  Lancet,  1891,  vol.  i.  p.  368. 

""  Trans.  Clin.  Soc.  Lond.  1889,  vol.  xxii.  p.  282. 

•■'  Berliner  klin.  Wochenschrift,  1892,  p.  879. 


378  THE   JEJUNUM   AND   ILEUM 

months.  Carver  ^  successfully  reduced  an  intussusception 
after  laparotomy  in  the  case  of  a  boy  whose  symptoms  had 
dated  back  seven  weeks.  For  twenty-five  days  prior  to  opera- 
tion it  is  stated  that  he  suffered  from  stercoraceous  vomiting. 
Another  point  of  practical  interest  is  the  death  and 
discharge  of  the  intussusceptum.     In  cases  which  run  either 


Fig.  54. — Intussusception  (O'Connor) 
lough  of  ileum  measuring  11 J  inches  iu  length  with  Meckel's  diverticulum ;  passed  i^^r  rectum. 

an  acute  or  chronic  course,  the  intussusceptum  may  become 
gangrenous ;  separation  of  the  dead  parts  will  then  commence. 
This  may  consist  in  the  discharge  of  considerable  segments  of 
the  bowel  or  of  disintegrated  shreds.  Death  of  the  patient 
usually  takes  place  in  acute  cases  before  separation  of  any 

'  Lancet,  1889,  vol.  i.  p.  171. 


INTUSSUSCEPTION  379 

part  of  the  bowel  is  possible.  Eccles,'  however,  reports  a  case 
of  spontaneous  separation  of  gut  in  an  infant  B  months  old. 
The  patient  had  had  symptoms  for  sixteen  days,  and  the  bowel 
protruded  from  the  anus.  Eecovery  ensued.  In  subacute  or 
chronic  cases  considerable-sized  sloughs  of  mucous  membrane 
are  sometimes  passed  per  rectum.  In  a  case  of  acute  intussus- 
ception reported  by  O'Connor,^  eleven  and  a  quarter  inches  of 
the  ileum  with  a  Meckel's  diverticulum  attached  were  cast 
off  and  ejected  by  the  rectum  eight  days  after  the  onset 
of  the  symptoms  (see  fig.  54).  The  boy  was  aged  18  years 
and  made  a  good  recovery.  In  another  case,  recorded  by 
Pullin,^  a  patient  aged  79  years,  after  thirteen  days  of  more  or 
less  acute  symptoms  of  obstruction,  passed  per  anum  a  sloughy 
mass  of  intestine,  measuring,  as  far  as  could  be  made  out, 
about  two  inches.  Whether  the  slough  was  from  the  large  or 
small  intestine  is  not  stated ;  quite  likely  it  was  not  possible  to 
determine  from  what  region  it  had  come.  The  patient  made 
a  speedy  and  complete  recovery. 

Short  of  gangrene,  the  extreme  distension  of  the  apex  and 
wall  of  the  intussusceptum  often  causes  fissures  in  the  en- 
gorged parts. 

Symptoms.— As  a  class  of  cases  of  intestinal  obstruction, 
none  presents  symptoms  which  frequently  so  definitely  indicate 
the  true  cause.  In  the  greater  proportion  of  the  acute  cases 
it  is  possible  to  arrive  at  a  correct  diagnosis. 

In  addition  to  the  usual  symptoms  of  acute  intestinal 
obstruction  already  described  under  Obstruction  from  Bands, 
the  existence  of  a  sausage-shaped  abdominal  tumour  situated 
in  the  left  lumbar  or  iliac  region,  tenesmus  with  the  passage  of 
blood  and  mucus  from  the  bowel,  and  the  presence  of  a  tumour 
to  be  felt  per  rectum,  prove  a  case  to  be  one  of  unmistakable 
intussusception. 

The  symptoms,  however,  are  frequently  not  so  typical.  In 
a  case  reported  by  Makins,^  there  was  neither  tenesmus  nor 
passage  of  blood  and  mucus.  The  child  died  in  forty-eight 
hours,  when  an  enteric  intussusception  was  discovered  situated 


'  St.  Bartholoview's  Hospital  Reports,  1892,  p.  97. 

2  Brit.  Med.  Joiirn.  1894,  vol.  ii.  p.  123.  ^  j;,j^_  iggg^  yoi_  i_  p_  82. 

^  Trans.  Clin.  Soc.  Lond.  1889,  vol.  xxii.  p.  282. 


380  THE   JEJUNUM   AND   ILEUM 

about  a  foot  above  the  ileo-csecal  valve.  Abbe  ^  reports  a 
still  more  striking  instance  of  what  might  be  termed  an 
abnormal  cause  of  the  disease.  A  lady  was  suddenly  seized 
with  pain  in  her  abdomen  below  the  umbilicus,  and  slight 
sensations  of  faintness  and  nausea.  The  symptoms  during 
the  week  prior  to  ojieration  were  very  scant,  no  tenesmus,  no 
mucus  and  bloody  stools,  nausea  and  vomiting  only  occasion- 
ally present,  and  temperature  normal.  No  tumour  could  be 
felt.  On  the  sixth  day  the  vomit  became  feculent.  At  the 
operation,  the  intussusception  was  found  eight  feet  from  the 
ileo-csecal  valve.     The  patient  died. 

A  closer  examination  of  the  symptoms  reveals  the  fact 
that  in  the  majority  of  instances  they  are  materially  affected  by 
the  situation  of  the  intussusception  and  the  completeness  of 
the  obstruction.  In  both  the  enteric  and  ileo-colic  varieties 
the  tumour  is  usually  small,  and  in  the  former  may  be  so 
buried  in  the  abdominal  cavity  among  other  coils  that 
it  cannot  be  felt.  Further,  in  both  varieties  tenesmus  is 
an  unlikely  symptom  ;  and  the  presence  of  bloody  mucus,  even 
suppose  blood  be  thrown  out  from  the  intussusceptum,  is  not 
likely  to  be  recognised,  should  such  be  passed  j^er  rectum. 

The  two  symptoms,  tenesmus  and  the  passage  of  blood 
and  mucus,  are  met  with  most  prominently  in  cases  where  the 
intussusceptum  has  descended  into  the  sigmoid  flexure  or 
rectum.  Here  the  sense  to  the  patient  of  something  distend- 
ing the  lower  bowel  evokes  persistent  efforts  for  its  expulsion  ; 
and  the  nearness  of  the  tumour  to  the  anus  allows  of  the 
unaltered  blood  being  recognised. 

The  completeness  of  the  obstruction  determines  the  mode 
of  onset  and  the  character  and  persistency  of  the  pain  and 
vomiting.  When  the  bowel  is  completely,  or  almost  completely, 
obstructed  at  the  outset,  the  seizure  is  sudden,  the  pain  is 
acute,  and  vomiting  soon  sets  in  and  persists.  On  the  other 
hand,  if  not  complete,  the  pain,  at  first  slight,  becomes  paro- 
xysmal in  character  ;  vomiting  is  infrequent,  but  increases,  like 
the  other  symptoms,  as  the  lumen  of  the  bowel  becomes  closed. 

It  is  unusual  to  meet  with  either  tenderness  or  distension 
of  the  abdomen  ;  when  they  do  appear  they  indicate  com- 
mencing peritonitis. 

'  New  York  Med.  Journ.  1891,  vol.  liv.p.  630. 


INTUSSUSCEPTION  3S1 

The  ileo-cfccal  variety  gives  rise  to  the  most  marked  kind 
of  tumour.  It  is  situated  usually  in  the  left  lumbar  and  iliac 
regions,  and  conveys  to  the  touch  a  swelling  the  shape  and 
consistency  of  a  sausage.  During  paroxysms  of  pain  it  becomes 
much  harder  and  more  prominent.  It  is  always  best  felt  after 
the  abdominal  parietes  have  been  completely  relaxed  by  the 
administration  of  an  anaesthetic.  When  the  tumour  descends 
sufficiently  low  to  be  felt  by  the  finger  in  the  rectum,  it  is 
said  to  feel  like  the  cervix  uteri.  In  some  cases  the  intussus- 
ceptum  passes  through  the  sphincter,  so  as  to  project  exter- 
nally ;  and  in  some  cases,  where  it  does  not  descend  to  the 
extent  of  extrusion,  it  frequently  causes  a  patulous  condition 
of  the  anus. 

Incompleteness  of  obstruction  gives  rise  to  the  two  clinical 
classes  of  subacute  and  chronic  cases,  the  symptoms  of  which 
are  frequently  so  vague  that  they  are  more  than  likely  to  be 
ascribed  to  some  cause  other  than  the  true  one. 

Patients  suffering  from  subacute  or  chronic  intussus- 
ception are  liable  to  be  attacked  by  pain  of  a  periodical 
and  colicky  character,  accompanied  with  vomiting  and  some- 
times tenesmus.  In  the  most  chronic  cases,  peristaltic  action 
of  the  intestines  can  be  observed  through  the  thinned  parietes. 
Inasmuch  as  the  ileo-csecal  variety  is  the  one  most  frequently 
found  in  these  cases,  it  is  often  possible  to  detect  a  tumour 
in  the  left  iliac  region.  It  occasionally  happens  that  complete 
obstruction  takes  place,  when  all  the  symptoms  become  acute. 
Failing  any  such  untoward  accident,  relief  may  come  throuoh  a 
s]3ontaneous  separation  of  the  intussusceptum  ;  or  the  patient 
will  continue  to  emaciate,  and  die  eventually  from  progressive 
exhaustion. 

In  some  cases  the  progress  of  a  natural  cure  is  suddenly 
terminated  by  the  onset  of  acute  symptoms  indicative  of  per- 
foration. The  patient  is  seized  with  acute  abdominal  pains, 
becomes  collapbed,  vomits,  and  the  abdomen  soon  distends 
and  becomes  tender  on  palpation.  The  clinical  significance  of 
these  symptoms  is  commencing  peritonitis,  and  their  explana- 
tion perforation  of  the  bowel  along  the  neck  of  the  intussus- 
ception. Either  ulceration  has  progressed  until  a  complete 
communication  has  become  established  between  tlie  general 
peritoneal  cavity  and  the  interior  of  the  bowel,  or  the  adhesion 


382  THE   JEJUNUM   AND   ILEUM 

of  the  entering  to  the  returning  layer  has  been  insufficient 
to  stand  the  strain  placed  upon  it  on  separation  of  the 
intussusceptum. 

Case  LXXVIII. — lleo-ccBcal  intussusception:  laparotomy.    Reduction. 

W.  S.,  aged  10  years,  a  healthy  lad,  was  suddenly  seized  on  the  evening 
of  March  4  with  severe  pains  in  the  abdomen.  On  the  following  morning, 
March  5,  at  5  a.m.,  he  commenced  to  vomit.  On  March  6  he  was  admitted 
into  the  Tyrone  County  Infirmary,  when  his  condition  was  as  follows : 
His  eyes  appeared  very  dull,  heavy  and  sunken  ;  face  pale  and  pinched  ; 
his  countenance  was  expressive  of  great  distress ;  his  lips  pale ;  tongue 
small,  dry,  and  brown  ;  teeth  slightly  coated  with  sordes.  He  lay  on  his 
back  with  his  knees  drawn  up,  complained  of  great  pain  in  the  abdomen, 
particularly  intense  in  the  right  iliac  region,  where  a  more  or  less  sausage- 
shaped  tumour  coiald  be  distinctly  made  out,  shifting  its  position  slightly 
at  intervals.  Dulness  existed  in  both  flanks,  with  slight  tympany  in  the 
central  region  of  the  abdomen.  Tenesmus  was  constant,  but  since  ad- 
mission he  had  pa-sed  no  blood,  mucus,  or  flatus.  His  parents  refusing 
operation,  conservative  measures  were  tried  till  March  8,  when  his  sym- 
ptoms became  more  urgent.  He  had  constant  hiccough,  with  retching  and 
constant  vomiting  of  dark  fluid  material.  Tenesmus  still  present,  and 
great  thirst.  Breathing  was  very  rapid  and  shallow ;  pulse  rapid  and 
thready ;  torpor  had  much  increased,  and  when  roused  he  could  only 
speak  in  a  whisper.  The  abdomen  was  much  more  swollen  and  tym- 
panitic, the  feet  and  legs  cold  and  clammy  ;  the  temperature,  which  had 
run  up  to  100  8°,  was  subnormal. 

Laparotomy  performed  four  days  after  the  onset  of  the  attack.  On 
opening  the  abdomen  a  considerable  quantity  of  dark- coloured  pus  oozed 
out.  The  coils  of  the  small  intestine  were  so  enormously  distended  with 
gas  that  they  tended  to  escape  like  balloons.  An  invagination  of  about 
six  inches  of  the  ileum  through  the  ileo-csecal  valve  was  found.  With 
some  little  difficulty  the  intussusceptum  was  withdrawn.  The  abdominal 
cavity  was  cleansed  and  drained.  The  boy  made  an  uninterrupted  re- 
covery.    (R.  E.  Thompson,  '  Brit.  Med.  Journ.'  1891,  vol.  ii.  p.  750.) 


CHAPTER  XLV 

INTUSSUSCEPTION  {continued),     tkeatment 

While  the  course  to  be  adopted  in  the  treatment  of  any  case 
of  intussusception  must  always  be  considered  solely  upon  the 
conditions  present  at  the  time,  still  it  will  simplify  the  discus- 
sion of  the  subject  if  some  sort  of  a  clinical  classification  be 
attempted  as  an  approximate  basis  for  the  pursuit  of  any 
particular  line  of  treatment. 


INTUSSUSCEPTION  383 

Cases  may  be  divided  into 

I.  Acute  seen  within  forty-eight  hours. 

II.  Acute  not  seen  till  after  forty-eight  hours. 

III.  Subacute. 

IV.  Chronic. 

I.  Acute  cases  seen  within  forty-eight  hours. — ^There  is 
always  some  hope  that  in  cases  thus  early  seen  reduction  may 
be  effected  without  laparotomy.  One  of  three  measures  may 
be  practised,  ahdoininal  taxis,  inflation,  or  injection.  In  every 
case  chloroform  should  be  administered. 

Abdominal  taxis. — This  method,  advocated  by  Jonathan 
Hutchinson  for  all  early  cases  of  acute  obstruction,  has  not 
been  practised  to  any  very  great  extent  for  intussusception. 
It  is,  however,  a  reasonable  measure,  and  worthy  of  trial  for 
this  class  of  case.  For  its  mode  of  performance  see  Operations 
upon  the  Intestines. 

Inflation. — Distension  of  the  rectum  and  colon  by  the 
forcible  introduction  of  gas  has  produced  successful  results. 
Cheadle  ^  succeeded  in  the  case  of  a  baby  aged  14  months. 
It  had  had  symptoms  for  six  days.  In  three  other  cases 
reported  by  the  same  author,^  success  also  followed  inflation. 
The  symptoms  in  these  cases  had  lasted  respectively  twenty- 
four  hours,  ten  and  a  half  days,  and  seven  days.  Williams  ^ 
succeeded  where  the  symptoms  had  lasted  for  twenty-four 
hours.  He  generated  carbonic  acid  in  the  bowel,  by  placing 
in  the  rectum  some  carbonate  of  soda  and  citric  acid. 

Case  LXXIX. — Intussusception.  Successful  reduction  by  inflation. 
A  boy  aged  14  months  was  admitted  into  hospital  with  typical  sym- 
ptoms of  intussusception,  which  had  already  lasted  six  days.  The  opera- 
tion, which  was  performed  under  chloroform,  was  thus  carried  out :  '  An 
ordinary  Higginson's  syringe  was  used,  and  the  bowel  was  inflated  with 
air  until  the  abdomen  became  decidedly  tense.  After  waiting  a  minute  or 
so,  the  air  was  allowed  to  escape,  and  on  examination  the  tumour  could 
still  be  felt  in  the  left  hypochondrium.  After  repeating  the  inflation,  only 
an  ill-defined  mass  could  be  made  out  to  the  right  of  the  umbilicus ;  and 
after  a  third  inflation  no  tumour  could  be  felt  in  any  part  of  the  abdomen. 
The  child  was  ordered  one  minim  of  liquor  opii  sedativus  every  three 
hours.     He  became  easier  after  the  operation,  the  pulse  improved,  and 

'  Lancet,  1889,  vol.  i.  p.  171.  ^  Ibid.  1886,  vol.  ii.  p.  7G6. 

3  Ibid.  1894,  vol.  i.  p.  537. 


384  THE   JEJUNUM   AND   ILEUM 

two  liquid  motions  were  passed  within  two  hours  after  the  inflation, 
unaccompanied  by  blood.  He  vomited  once,  immediately  upon  being  put 
under  chloroform,  but  had  not  done  so  since.'  (Cheadle,  '  Lancet,'  1889, 
vol.  i.  p.  171.) 

For  instructions  regarding  the  performance  of  inflation  see 
Operations  upon  the  Intestine. 

Injection. — Distension  of  the  bowel  from  below  with  water, 
has,  judging  by  statistics,  been  more  frequently  adopted  than 
distension  by  inflation.  Eccles  ^  gives  three  cases  which  had 
been  successfully  so  treated  at  St.  Bartholomew's  Hospital 
between  the  years  1880  and  1891.  Pye-Smith^  succeeded  in 
the  case  of  a  boy  aged  14  months,  who  had  symptoms  for  six 
days.  Pollard,^  after  three  separate  injections  in  the  same 
case,  reduced  an  intussusception  of  ten  hours'  duration ;  and 
Bruce  Clarke  ^  one  of  nine  days. 

Both  methods  of  inflation  and  injection  are,  however,  not 
void  of  danger.  Knaggs  ^  illustrates  by  eight  fatal  cases  some 
of  these  dangers.  In  seven  rupture  occurred.  In  six  of  these 
the  ages  were  from  5  to  7  months.  In  one,  only  nine  ounces 
of  water  were  injected,  '  when  a  rumbling  noise  was  heard  in 
the  abdomen.'  In  the  eighth  case  the  child  became  collapsed 
and  convulsed  immediately  before  death. 

Failing  in  any  reasonable  attempt  by  one  or  more  of  these 
methods  to  reduce  the  bowel,  laparotomy  should  be  performed 
without  delay. 

Case  IJ^'K^.— Intussusception  treated  by  injection  :  rupture.  Death. 
The  baby  was  aged  3  months.  About  a  pint  of  fluid  was  slowly  and 
carefully  injected.  Suddenly  the  abdomen  became  more  tense,  and  it  was 
evident  that  perforation  of  the  bowel  had  occurred.  The  breathing  be- 
came laboured  and  slower,  and  the  heart's  action  almost  imperceptible. 
The  child  died  within  an  hour.  At  the  post  mortem,  a  small  rent  was  found 
at  a  point  corresponding  with  the  lowest  part  of  the  intussusception.  A 
small  quantity  of  the  enema  fluid  had  escaped  into  the  peritoneal  cavity. 
(Parker,  '  Trans.  Clin.  Soc.  Lond.'  1892,  vol.  xxi.  p.  244.) 

II.  Acute  cases  not  seen  till  after  forty-eight  hours. — Con- 
siderable difference  of  opinion  still   exists   among  surgeons 

'  St.  Bartholometo's  Hospital  Reports,  1892,  p.  97. 
'  Lancet,  1892,  vol.  ii.  p.  1441.  ^  j5^j_  p   §80. 

*  St.  Bartholomeiu's  Hospital  Reports,  1892,  vol.  xxviii.  ]).  115. 
5  Lancet,  1887,  vol.  i.  p.  1125. 


IXTUSSL'SCEPTIOX 


385 


regarding  the  proper  procedure  to  adopt  when  a  case  is  not 
seen  till  after  the  symptoms  have  lasted  for  a  couple  of  days. 
With  the  facilities  and  needful  precautions  which  exist  in  a 
hospital,  most  surgeons  would  probably  advocate  immediate 
laparotomy ;  but,  under  less  favourable  circumstances  and 
surroundings,  should  time  be  spent  in  trying  the  more  conserva- 
tive measures  above  described—  taxis,  inflation,  or  injection  '? 
It  is  not  possible  to  lay  down  any  definite  rule  in  the  latter 
case,  for  not  only  is  there  the  question  of  time  to  be  con- 
sidered, but  the  condition  of  the  patient.  Acute  symptoms 
may  have  existed  for  three,  four,  or  more  days,  and  the  patient 
still  not  be  profoundly  ill.  It  would  therefore  seem  quite 
justifiable  under  such  circumstances  to  run  w^hatever  risk  there 
might  exist  and  attempt  conservative  measures,  especially 
also  in  the  light  of  the  success  which  has  attended,  as  shown 
above,  in  cases  of  six,  seven,  and  nine  daj^s'  duration  of 
symptoms.  Failing,  however,  success  by  injection  or  inflation, 
no  further  delay  should  be  allowed,  and  laparotomy  at  once 
proceeded  with.  As  an  illustration  of  successful  reduction 
after  laparotomy,  see  Case  LXXVIII.,  p.  382. 

The  performance  of  laparotomy  for  acute  cases  of  intussus- 
ception must  be  looked  upon  as  a  serious  operation  in  the 
case  of  children.  "What,  however,  it  has  to  be  contrasted 
with,  is  the  almost  inevitably  fatal  result  to  be  expected  if  the 
abdomen  be  not  opened.  The  table  subjoined  will  at  least 
lend  considerable  encouragement  to  the  practice,  for  every 
success  must  be  reckoned  as  a  life  saved. 

Table  of  Successful  Cases  of  Laparotorny  for  Intusstiscej^tion 
from  1891  to  1895  inclusive 


Time  intervAiing 

Operator 

Variety  of 
Intussusception 

between  onset  of 

S3  mptoms  and 

operation 

Nature  of 
Operation 

Eeference 

Lange . 

Not  given 

Laparotomy  and 
reduction 

New    Yor 

Journ.  Med. 
liii.  37-i     1891, 

jrcCurnev  . 

Enteric    C2    feet 
above  the  ileo- 
csecal  valye) 

3  days 

V 

Ihid.  p.  431 

R.  E.  Thornpsou . 

4    „ 

" 

hrit.  Med.  .Journ. 
1891  ii.  750 

Howard  Marsh   . 

2(1  hours 

" 

Lancet,  1891,  i. 
368 

Win.  MacEweii  . 

Ileo-colic 

Not  given 

GUisgow  Med, 
.loam.  1892, 
xxxvii.  27(j 

c  c 


386  THE   JEJUNUM   AND   ILEUM 

Table  of  Successful  Cases  of  Laparotomy  Sc.  (continued) 


Time  intervening 

Operator 

Variety  of 
Intussuscepuon 

between  onset  of 

symptoms  and 

operation 

Nature  of 
Operation 

Reference 

Lindemann 

5  days 

Laparotomy  and 

Berl.klin  Wochert. 

^ 

reduction,     in 
addition  union 
of  a  gangrenous 
patcli  to  parie- 
tal wound 

1892,  xxix.  651 

Shepherd     . 

60  hours 

Laparotomy  and 
reduction 

Lancet,   1892,   ii. 
1155 

Bruce  Clarke 

14    „ 

" 

St.  Bart.'s  ffosp. 
Reports,     1892, 
xxviii.  115 

Ven-al . 

Ileo-cjecal 

12     „ 

" 

Brit.  Med.  Joiirn. 
1893,  ii.  1375 

Kbrte  . 

iS^ot  given 

" 

Ann.   Univ.  Med. 
Sci.    1893,    iii. 
C— 51 

Lockwood  . 

Ileo-colic 

28  hours 

" 

Lancet,    1893,     i. 
1303 

Cjtterell     . 

Not  given 

" 

Brit.  Med.  Journ. 
1894,  i.  803 

R.  Godlee    . 

Ileo-caeoal 

26i  hours 

>. 

Ibid.  p.  347 

A.  E.  Barker 

Enteric 

36      „ 

„ 

Jbid. 

Ochener 

Not  give.i 

Ann.  Univ.  Med. 
Sci.    1894,    iii. 
C— 29 

J.  L.  Stretton     . 

2  days 

" 

Lancet,    1894,   ii. 
797 

A.  E.  Barker 

Ileo-CEecal 

2    „ 

" 

Brit.  Med.  Journ . 
1894,  ii.  1237 

„    (2nd  case) 

Ileo-CEecal  (child 
aged  4  montlis) 

2    „ 

" 

Ibid. 

W.  Meyer    . 

Doub'e  :  primary 

8    „ 

Laparotomy  ;  re- 

Private letter  to 

eutei-ic,  Sfcoii- 

duction  first  of 

author 

dary  ileo-CKcal 

primary,   then 
of     secoudary. 
Tumour,      in- 
volving    exci- 
sion    \\  inch 
of  ileum 

a.  W.  Ridley       . 

Ileo-ceecal  (aged 

41     hours     after 

Laparotomy 

Brit.  Med.  Journ. 

11  months) 

supposed      re- 
duction by  in- 
flation 

1894,  i.  911 

Banks . 

Enteric     (ileum) 

G  days 

Resection  of  gan- 

Lancet,   1895,    i. 

( boy     aged     7 

grenous  bo  we', 

487 

years) 

c 

end-to-end  ana- 
stomosis— Mur- 
phy's button 

E.W.  Roughton. 

Ileo-cfecal 

2 

Laparotomy  and 
reduction 

Ibid  p.  483 

T.  P.  Pick  . 

Ileo-caecal 

2     „ 

» 

Ibid.  p.  745 

J.  Crawford 

Ileo-csecal 

A  few  hours 

7'raM.!.          Path. 

Renton 

and  Clin.  Soc. 
Glasg.   1895,  V 
177 

Fred.  Eve 

Ileo-CEecal 

1)          i» 

jj 

Brit.  Med  Journ. 

(11  months  old) 

1895,11.968 

Column  2  contains  the  kind  of  intussusception  present 
when  stated  in  the  report. 

Column  3  contains  the  interval  of  time  which  elapsed 
between  the  onset  of  the  symptoms  and  the  performance  of 


IXTURSUSCEPTrOX  387 

the  operation.  Unfortunately  it  has  not  been  found  possible 
to  obtain  this  in  every  case.  From  those  given,  however,  it 
will  be  seen  that  the  time  varied  between  twelve  hours  and 
eight  days. 

Column  4  contains  the  nature  of  the  operation  performed. 
It  will  be  observed  that  in  every  instance  except  two  the 
operation  consisted  in  the  reduction  of  the  bowel  by  manipu- 
lation. The  exceptional  cases  were  those  of  Lindemann  and 
Banks,  where,  after  reduction,  the  former  operator  thought  it 
advisable  to  stitch  a  part  of  the  bowel  which  had  become 
gangrenous  to  the  parietes,  and  the  latter  to  excise  the  part. 
A  study  of  this  table  of  successful  cases  after  laparotomy  seems 
to  show  that  success  almost  entirely  depends  upon  the  possi- 
bility of  reducing  the  bowel.  If  after  opening  the  abdomen 
reduction  proves  impossible,  then  unfortunately  there  are  only 
two  cases  recorded — those  of  Lindemann  and  Banks — to  show 
that  any  additional  measure  which  has  been  practised  has 
proved  successful.  On  the  other  hand,  there  are  not  a  few 
cases  reported  to  demonstrate  the  lamentable  fact  that  the 
formation  of  an  artificial  anus  or  the  resection  of  the  intus- 
susception has  proved  of  no  avail.  In  1888  A.  E.  Barker  ^ 
published  statistics  of  operations  for  intussusception.  Up  to 
that  date  he  found  recorded  nine  recoveries.  In  every  instance 
the  bowel  was  simply  withdrawn.  In  no  case  does  there 
appear  to  have  been  a  successful  result  after  excision  or  the 
formation  of  an  artificial  anus  with  or  without  opening  the 
abdomen.  The  longest  interval  between  the  onset  of  symptoms 
and  the  performance  of  operation  was  eighteen  days. 

The  question,  however,  in  spite  of  these  discouraging  facts, 
is.  What  under  the  circumstances  ought  the  surgeon  to  do 
when  he  finds  that  by  no  manipulative  power  can  he  push 
back  or  withdraw  the  intussusceptum  ?  Ought  he  to  close  the 
abdomen  and  trust  to  nature's  spontaneous  efforts  at  separa- 
tion of  the  part ;  or  ought  he  to  proceed  to  perform  one  of 
those  various  operations  which  have  already  been  attempted, 
although  with  almost  no  success  ?  To  trust  to  nature  is 
practically  to  abandon  the  case  to  death ;  but  to  adopt 
measures  which  are  known  under  other  circumstances  to  have 
been  successful  is  to  act  where  there  is  some  just  reason  for 

'  Lanczt,  1888,  vol.  ii.  p.  2G2. 

c  c  2 


388  THE   JEJUNUM   AND   ILEUM 

hoping  that  life  may  be  saved.  As  no  one  method  can  claim 
any  particular  success  in  the  class  of  cases  under  discussion, 
there  is  little  use  in  placing  before  the  reader  one  operation 
more  prominently  than  another.  Time  is  always  a  serious 
item  ;  and  the  condition  of  the  patient  may  determine  the 
method  to  be  selected. 

A  fsecal  fistula  can  be  formed  by  bringing  a  loop  of  the 
distended  bowel  above,  to  the  abdominal  incision  and  securing 
it  there  ;  or  the  median  incision  can  be  closed  and  a  loop  of 
bowel  brought  out  in  the  loin  ;  or  an  artificial  anus  can  be 
produced  by  dividing  the  bowel  above  the  intussusception, 
closing  the  distal  end  and  bringing  the  proximal  out.  A 
lateral  anastomosis  may  be  performed  between  the  distended 
bowel  above  and  the  collapsed  portion  below.  Lastly,  the  part 
can  be  excised,  and  an  end-to-end  or  lateral  anastomosis 
effected  either  by  Murphy's  button  or  by  some  other  method. 

III.  Subacute  cases. — When  the  symptoms  are  not  urgent, 
or,  if  acute  at  first,  shortly  subside,  subsequently  under- 
going exacerbations,  careful  and  repeated  endeavours  to  reduce 
the  bowel  by  taxis,  inflation,  or  injection  should  be  made 
without  delay.  Any  very  obvious  and  lasting  increase  in 
severity,  however,  of  the  symptoms  should  at  once  deter- 
mine operative  intervention,  and  all  that  has  been  said  above 
in  the  case  of  acute  cases  becomes  applicable  here. 

If  the  administration  of  oj)ium  is  admitted  as  a  suitable 
drug  in  any  case  of  intestinal  obstruction,  then  its  use  in  this 
particular  class  appears  particularly  advisable.  Anything 
which  will  quiet  the  peristaltic  action  of  the  bowel  is  likely  to 
prevent  the  onset  of  more  acute  mischief  at  the  seat  of  disease. 
Where  therefore  no  marked  urgency  exists,  and  delay  seems 
advisable,  some  solid  opium  and  belladonna  may  be  adminis- 
tered by  the  mouth.  Further,  the  stomach  may,  with  ad- 
vantage, be  washed  out,  and  all  food  should  be  withheld  from 
the  mouth,  nourishment  being  introduced  in  the  form  of 
enemata. 

Case  L1X.X.XI.— Stibacute  intussuscei^tion  :  seven  wecl^s'  duration: 
laparotomy :  reduction.     Recovery, 

A  child  aged  2  years  and  9  months  was  seized  with  somewhat  acute 
symptoms,  consisting  of  violent  abdominal  pain  over  the  right  iliac  region, 
and  vomiting.     He  remained  ill  for  three  days,  when  a  round  worm  was 


iXTUssua'ErTiox— voLVUi.rs  ypg 

passed,  and  his  bowels  oj^ened  for  the  first  time,  although  only  a  thin 
yellowish  motion  with  a  little  blood  came  away.  After  ten  days  the 
pain  subsided  and  he  had  two  soft  motions  and  was  able  to  retain  a  little 
beef  tea.  He  continued  in  this  improved  state  for  about  a  fortnight,  when 
the  pain  and  vomiting  returned  more  severely  than  before.  The  vomiting 
now  commenced  to  be  stex'coraceous,  and  the  bowels  acting  frequently, 
only  brought  forth  blood  and  mucus.  When  admitted,  seven  weeks  after 
the  onset  of  the  sj'mptoms  and  twenty-five  days  after  the  commencement 
of  stercoraceous  vomiting,  he  was  extremely  emaciated  ;  the  abdomen 
was  slightly  and  uniformly  distended.  Laparotomy  wa5  performed,  and 
with  some  little  difficulty  the  intussusceptum  was  withdrawn.  (Carver, 
'Lancet,'  1889,  vol.  i.  p.  171.) 

IV.  Chronic  cases. — The  treatment  of  chronic  cases  consists 
either  in  a  careful  regulation  of  the  bowels,  \Yhereby  an  effort 
is  made  to  prevent  anything  like  accumulation  taking  place 
above  the  narrowed  part ;  or  in  relief  by  operation.  Two  cases 
of  successful  excision  have  been  recorded,  one  by  Eosenthal  ^ 
and  one  by  Lauenstein.  In  the  latter  instance  a  man  aged 
56  years  had  had  sjanptoms  for  three  months.  The  part 
removed  measured  twenty  centimetres  in  length,  that  is  to 
say,  a  total  length  of  bowel  of  sixty  centimetres.  The  intus- 
susception was  of  the  ileo-cgecal  variety  ;  so  that  the  operation 
consisted  in  stitching  the  ileum  to  the  caecum. 


CHAPTEE   XL VI 

4.    VOLVULUS 


Twisting  of  the  small  intestine  is  a  comparatively  rare  cause 
of  obstruction.  It  is  found  most  frequently  involving  the 
lower  part  of  the  ileum,  and  dependent,  as  an  indirect  cause, 
upon  some  extra  length  of  the  mesentery  at  that  particular, 
part.  The  greater  elongation  of  the  mesentery  may  be  of 
congenital  origin,  or  due  to  prolonged  stretching,  the  result  of 
an  old  hernial  loop  ;  but  from  whatever  cause  produced,  it  has 
the  effect  of  producing  an  axis  around  which  the  bowel  may 
turn. 

In  most  instances  a  complete  turn  is  effected,  usually  from 
left  to  right,  but  any  degree  between  a  half-turn  and  a  com- 

'   Berliner  klin.  Wochcnschrijt,  18f0.  Xo.  41.  p.  Ol-i 


SCO  THE   JEJUNUM   AND   ILEUM 

plete  one  may  take  place.  In  a  case  reported  by  Dorfler,'  the 
bowel  "was  twisted  several  times  upon  itself.  A  rare  form  is 
where  one  coil  of  intestine  becomes  twisted  round  another.  An 
illustration  of  such  an  accident  is  seen  in  the  case  narrated 
in  detail  below. 

In  many  instances  it  is  impossibb  to  ascribe  any  direct 
cause  for  the  bowel  becoming  twisted  ;  in  others,  however,  a 
definite  exciting  cause  is  found.  Thus,  in  a  case  reported  by 
Hawkins,^  a  woman  died  of  acute  obstruction  the  result  of  a 
slight  blow  on  the  abdomen.  At  the  post  mortem  a  figure-of- 
eight  twist  of  the  bowel  w^as  found.  Similarly,  in  a  case  re- 
ported by  Stanley,^  a  slight  blow  on  the  abdomen  of  a  child 
aged  5  years,  while  at  play,  caused  acute  obstruction,  from 
which  it  died  in  the  course  of  forty-eight  hours.  At  the  post 
mortem  a  volvulus  was  found  about  thirty  inches  from  the 
pylorus.  Pennington^  reports  the  case  of  a  girl  aged  18 
years,  who  died  of  a  twist  of  the  ileum  which  came  on  after 
violent  exercise.  Briddon  ^  records  a  case  where  the  volvulus 
was  produced  by  the  axial  rotation  of  a  large  lipoma  growing 
from  the  mesentery.  The  tumour  was  removed,  the  bowel 
untwisted,  and  the  patient  made  a  good  recovery.  It  is 
quite  possible  that  adhesions  by  binding  down  a  loop  of  bowel 
at  any  spot  may  lead  to  that  particular  portion  becoming 
twisted.  Such  appears  to  be  exemplified  in  a  case  of  Callender's 
quoted  by  Hutchinson,^  and  in  a  case  reported  by  Ashby,^ 
where  nearly  the  whole  of  the  small  intestine  was  twisted. 
Considerable  adhesions  were  found  to  have  existed  previous  to 
the  acute  volvulus  which  caused  death.  In  some  cases  it 
would  appear  that  the  existence  of  a  gall  stone  in  the  bowel 
has  been  the  cause  of  rotation.  Mayo  Eobson  ^  reports  two 
such  cases.  The  twisting  of  a  loop  of  bowel  after  slipping 
beneath  a  band  is  probably  due  to  the  traction  of  the  mesen- 
tery.    Pitt^  has  reported  two  cases  of  volvulus  of  the  ileum 

'   Brit.  Med.  Journ.  Epitome,  1894,  vol.  i.  p.  18. 

"^  Brit.  Med.  Journ.  1892,  vol.  ii.  p.  944.  3  Ibid. 

*  Annual  of  the  Universal  Medical  Sciences,  1894,  vol.  iii.  C — 25. 

*  Ibid.  *  Archives  of  Surgery,  18S0,  vol.  i.  p.  13. 
'■  Brit.  Med.  Journ.  1891,  vol.  i.  p.  413. 

8  Trans.  Royal  Med.-Chir.  Soc.  1895. 

s  Trans.  Path.  Soc.  Lond.  1891,  vol.  xlii.  p.  123. 


VOLVULUS  391 

causing  death  in  newly  born  children,     Cripps '  also  reports 
a  similar  instance. 

The  effect  of  torsion  upon  the  vitality  of  the  bowel 
depends  upon  the  tightness  of  the  twist.  In  some  instances 
this  is  so  slight  as  to  do  little  more  than  obstruct  the 
lumen  of  the  bowel ;  but  on  the  other  hand  it  may  be  so 
serious  as  to  produce  an  effect  similar  to  strangulation.  In 
a  case  reported  by  McAlister,'^  a  loop  of  ileum  about  eight 
inches  long  was  twisted  upon  itself  from  left  to  right.  The 
part  of  the  gut  where  the  twist  existed  was  very  dark  in 
colour,  and  looked  gangrenous.  Small  spots,  which  also 
looked  gangrenous,  were  found  throughout  the  small  intes- 
tine. The  bowels  generally  were  congested  and  very  much 
distended  with  gas. 

Symptoms, — There  are  no  symptoms  sufficiently  distinctive 
of  volvulus  to  admit  of  it  being  distinguished  from  obstruction 
due  to  other  causes.  The  patient  may  be  seized  suddenly 
with  great  abdominal  pain,  vomiting,  and  collapse  ;  or  the 
onset  may  be  more  gradual,  with  vague  sensations  of  intestinal 
discomfort,  colicky  pains,  constipation,  and  possibly  some 
abdominal  tenderness. 

It  is  probable  that  the  variations  in  the  symptoms  are  due 
to  the  degree  of  rotation,  or,  in  other  words,  to  the  complete- 
ness or  otherwise  of  the  obstruction  resulting  from  the  torsion. 

Treatment. —Were  it  possible  to  make  a  correct  diagnosis, 
probably  no  class  of  cases  of  intestinal  obstruction  would 
respond  more  favourably  to  treatment  by  abdominal  taxis. 
The  rigorous  shaking  it  involves,  together  with  the  manipula- 
tion of  the  abdomen,  would  very  likely  untwist  the  involved 
loop.  Where,  however,  this  measure  is  either  not  attempted 
or  fails,  none  can  prove  of  any  avail  except  laparotomy. 
The  few  cases  tabulated  below  show  the  success  which  may  be 
expected  to  attend  such  treatment. 

The  same  rule  regarding  early  operation  applies  in  this  class 
of  cases  equally  with  all  others  of  a  similar  character.  The 
untwisting  of  a  volvulus  before  material  change  has  taken 
place  in  the  affected  part  is  one  of  the  simplest  of  intra- 
abdominal operations  ;  but  if  the  operation  be  delayed  until, 

'  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  ii.  L — 15. 
2  IW^.  vol.  iii.  C-61. 


3P: 


THE    JEJU^'Ol    A^D   ILEIM 


Table  of  Successful  Cases  of  Laparotomy  for  Volvulus  of  Small 
Intestine  from,  1891  to  1895  inclusive 


Operator 


G.  Pi.  Turner 

Ddrfler 

Briddon 

Mayo  Robson 
„     (2ndcai=e) 


Nature  of 
Yolvulus 


Bowel  twisted 
several  times 
upon  itself 

Due  to  axial  rota- 
tion of  large 
lipoma  growing 
in  mesentery 

Due  to  gall  stone 


Due  to  gall  stone 


Time  intervening 

between  onset  of 

symptoms  and 

operation 


Not  given 

24  lionrs 

2  days 

Not  given 


Nature  of 
Operation 


Laparotomy  and 
untwisting 


Laparotomy,  un- 
twisting ;  re- 
moval of 
tumour 

Laparotomy  and 
untwisting 


Ann.  Univ.  Med. 
^•c^■.  1892,  iii. 
C— 61 

Brit.  Med.  Journ. 
1892,  ii.  944 

Ihid.      Epitome, 

1894,  i.  18 

Ann.  Univ.  Med. 
Sci.  1894,  iii. 
0—25 

JBrif.  Med.  Journ. 

1895,  i.  19i 


as  in  McAlister's  case  above  quoted,  the  part  is  almost  gan- 
grenous, more  extensive  operative  interference  will  be  neces- 
sary, and  as  a  consequence  the  prognosis  is  less  hopeful. 
All  that  has  been  said  with  reference  to  gangrenous  gut 
from  internal  strangulation  by  bands  or  other  agents  applies 
here,  either  the  part  must  be  excised  and  an  end-to-end  or 
lateral  anastomosis  effected,  or  a  fgecal  fistula  or  an  artificial 
anus  formed. 

Case  LXXXII. — Volvulus  of  ileum  the  result  of  trauviatism  : 
laparotomy  :  untivisting.     Becovery. 

A  boy  aged  7  years  fell  some  twelve  feet  against  the  pole  of  a  boat  and 
tlien  into  the  mud  of  the  river.  On  admission  he  was  much  collapsed  and 
vomited  bihous  matter  several  times.  He  soon  became  very  restless, 
rolling  himself  about  in  bed,  his  legs  were  drawn  up,  and  there  was  much 
abdominal  pain  complained  of,  especially  in  the  right  iliac  fossa.  There 
was  considerable  tenderness  in  this  situation,  but  no  abdominal  distension, 
no  signs  of  external  injury.  There  was  some  tenesmus,  but  no  flatus  or 
fteces  passed.  Laparotomy  was  performed  twenty-four  hours  after  the 
accident.  On  examining  the  small  intestine,  an  entanglement  was  felt 
just  to  the  left  of  the  middle  line.  The  mass  of  entangled  intestines  was 
easily  unravelled.  The  region  of  the  gut  affected  was  the  ileum.  In  two 
separate  places  there  were  collapsed  portions  of  bowel.  The  boy  made  an 
uninterrupted  recovery. 

The  case  illustrates  one  of  the  rarer  forms  of  volvulus  where  one  loop 
of  intestine  becomes  twisted  round  another.  (G.  E.  Turner, '  Trans.  Med. 
Soc'  1893,  vol.  xvi.  p.  16.) 


STRICTURE  393 

CHAPTER    XLVII 

5.    STRICTURE 

In  speaking  of  stricture  of  the  small  intestine  it  must  be 
understood  that  only  such  contractions  of  the  calibre  of  the 
canal  as  result  from  some  form  of  inflammation  in  the  coats 
of  the  bowel  are  included  under  the  term.  Stricture  from 
malignant  disease,  similar  to  that  found  in  other  portions  of 
the  alimentary  canal,  is  almost  unknown.  Narrowing  of  the 
canal  from  external  pressure  by  tumours,  abscesses,  &c.  will 
be  discussed  later ;  while  constrictions  the  result  of  kinking 
and  twisting  have  already  been  dealt  with. 

The  kind  of  stricture  therefore  embraced  under  the  term 
is  strictly  of  a  cicatricial  character,  arising  in  most  instances 
from  previous  ulceration,  and  only  rarely  from  a  chronic 
inflammatory  infiltration  of  the  intestinal  walls,  of  a  character 
similar  to  the  gonorrhoeal  stricture  of  the  urethra. 

Two  forms  of  ulcer  met  with  in  the  small  intestine  have 
already  been  described,  the  typhoid  and  the  tubercular.  The 
former  only  very  rarely  gives  rise  to  stenosis  in  the  process  of 
healing.  I  have  not  been  able  to  find  a  single  recorded  case, 
and  can  only  refer  to  the  solitary  instance  quoted  by  Treves,' 
which,  after  a  critical  examination  of  other  cases,  that  author 
believes  to  be  the  only  reliable  example. 

Tubercular  ulceration,  on  the  other  hand,  affords  numerous 
instances,  and  is  indeed  a  most  fruitful  source  of  stricture. 
Both  from  the  pathological  course  which  these  ulcers  pur- 
sue, and  the  frequency  with  which  they  are  met  with,  there  is 
every  reason  to  expect  that  they  should  frequently  give  rise 
to  stenosis. 

As  already  described,  the  tendency  of  a  tubercular  ulcer  is 
to  extend  circumferentially — that  is,  its  course  round  the  bowel 
renders  the  subsequent  process  of  healing  most  effectual  in 
the  production  of  stricture.  The  seat  of  the  stricture,  like 
the  ulcer,  is  most  commonly  in  the  lower  part  of  the  ileum, 
although  it  may  be  found  in  any  part  of  the  small  intestine. 

'  Page  255, 


394  THE   JEJUNUM   AND   ILEUM 

Accordirg  to  Konig,'  who  reports  five  cases  of  stricture  the 
result  of  tubercular  ulceration,  the  condition  is  most  often 
met  with  in  persons  between  20  and  30  years  of  age,  and  most 
frequently  in  those  who  suffer  from  tubercular  lesions  in  other 
parts. 

While  the  cause' of  the  symptoms  may  be  one  particular 
stricture,  others  may  exist  which  are  incapable  of  obstruct- 
ing to  any  appreciable  extent  the  normal  passage.  In  a  case 
reported  by  Voehts  (see  below),  one  stricture  was  situated  ten 
inches  above  the  ileo-caecal  valve,  while  a  second  was  found 
about  two  yards  higher  up. 

One  of  the  most  unmistakable  evidences,  from  a  patho- 
logical aspect,  that  a  particular  stricture  is  of  tubercular  origin, 
is  the  existence  of  miliary  tubercles  infiltrating  the  intestinal 
walls  in  the  immediate  neighbourhood  of  the  lesion. 

Case  LXXXIII. — Ttihercular  stricture  of  the  intestine  :  excision. 
Recovery. 

A  woman  aged  38  years  had  been  subject  to  attacks  of  sharp  pain 
in  the  abdomen,  together  with  vomiting.  These  attacks  would  set  in 
suddenly  and  her  abdomen  become  meteorically  distended.  If  flatus 
could  be  passed,  the  pains  would  cease  and  the  seizure  be  over.  Compres- 
sion of  a  loop  of  intestine  was  suggested.  Laparotomy  was  performed. 
Two  strictures  were  discovered,  one  ten  inches  above  the  ileo-caecal  valve, 
and  the  other  about  two  yards  higher  up.  The  intestinal  convolutions 
were  found  to  be  injected  and  infiltrated  with  miliary  tubercles.  The  con- 
tracted portions  were  resected,  about  six  or  eight  centimetres  being  extir- 
pated. The  operation  lasted  three  hours  Forty-five  hours  later,  flatus 
was  passed,  and  the  patient  recovered  without  accident  or  reaction.  Five 
months  after,  she  was  in  complete  health.  (Chr.  Voehts,  '  Annals  of 
Surgery,'  1893,  vol.  xviii.  p.  579.) 

Syphilis  is  another  cause  of  stricture.  According  to 
Eieder,'-^  who  has  investigated  the  subject,  the  lesions  produc- 
tive of  obstruction  are  most  frequently  met  with  in  the  upper 
part  of  the  small  intestine.  This  lesion  appears  to  consist  in 
an  increase  of  the  connective  tissue,  at  first  in  the  submucosa, 
and  later  in  the  other  coats. 

Another  comparatively  infrequent  source  of  stricture 
is  the  injury  which  a  loop  of  bowel  may  receive  when  strangu- 
lated in   one  of  the  usual  abdominal  apertures    (see   Plate 

'  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  i.  D— 31. 
=  Ihid. 


PLATE    XVIII. 


Fig.  55.— Striciure  of  Small  Intestine,  the  result  of  a  strangulated  hernia, 
operated  upon  eight  months  previously.  A  piece  of  whalebone  above  the 
stricture  passes  through  a  perforation  which  occurred  during  life.  (W.I.M., 
GUis.) 


STRICTURE  39/5 

XVIII,  fig.  55).  Several  cases  have  been  recorded  where, 
after  a  certain  period  has  elapsed  from  the  time  of  operation, 
symptoms  of  obstruction  set  in.  When  a  loop  of  intestine 
becomes  nipped  at  one  of  the  rings,  the  part  most  liable  to 
suffer  is  the  mucous  membrane.  It  is  well  known  that  ulcera- 
tion may  take  place  here,  while  very  little  mischief  to  the 
external  serous  coat  is  visible.  The  injury,  however,  may  be 
of  a  more  extensive  kind,  involving  all  the  coats  ;  so  that 
although  perforation  may  not  take  place,  yet  the  damage  to 
the  bowel  may  be  sufficiently  great  to  cause  some  sloughing 
of  the  whole  wall,  which  will  necessarily  lead  to  a  considerable 
formation  of  cicatricial  tissue  in  the  j^rocess  of  repair.  In  two 
ways,  therefore,  stricture  may  result  from  strangulated  hernia  : 
either  the  mucous  membrane  may  ulcerate  and  lead  to  the 
formation  of  circular  stricture,  or  a  portion  of  the  wall  die 
and  be  repaired  by  cicatricial  tissue. 

The  cases  recorded  are  too  few  to  admit  of  any  statement 
regarding  the  relative  frequency  of  stenosis  after  either  in- 
guinal or  femoral  hernia.  In  the  case  recorded  by  Pitt  (see 
below),  the  hernia  was  a  femoral  one  ;  while  in  one  reported 
by  Garre  '  it  was  an  inguinal.  The  period  at  which  symptoms 
of  stricture  appear  after  the  accident  of  strangulation  appa- 
rently vary  considerably.  In  Pitt's  case  they  commenced  five 
days  after  the  hernia  was  reduced ;  while  in  Garre's  it  was 
nine  weeks. 

Case  LXXXIV. — Stricture  of  ileum,  secondary  to  ulceration  produced 
by  strangulation  of  the  boivel  in  a  femoral  hernia  :  perforation.  Death, 

Sarah  D.,  aged  43  years,  had  suffered  from  reducible  femoral  hernia. 
Eleven  weeks  prior  to  admission  into  hospital  she  was  standing  on  a  chair 
hanging  some  clothes.  In  so  doing  she  strained  herself,  and  both  hernife 
came  down.  She  was  in  intense  pain  and  had  to  be  carried  to  her  bed. 
The  hernige  remained  down  for  a  week,  when  they  were  reduced  and  the 
bowels  opened  with  an  enema. 

Vomiting  commenced  five  days  after  the  accident,  and  from  that  time 
on,  it  continued  with  variable  intermittence.  Her  bowels  became  very 
irregular.  She  always  felt  pains  in  the  back  when  they  moved.  Abdo- 
minal pain  came  on  in  paroxysms  lasting  a  quarter  to  half  an  hour. 

When  admitted  she  was  seen  to  be  greatly  emaciated,  and  in  appear- 
ance almost  moribund.    The  abdomen  was  distended  and  tympanitic,  \^■ith 

'    Cenlralblatt  fiir  CJihiirgic,  18{!2,  p.  603. 


396  THE   JEJUNUM   AND   ILEUM 

no  evidence  of  tumour.  There  was  tenderness  and  pain  in  tlie  epigastric 
and  right  hypochondriac  regions.  When  paroxj'sms  of  pain  came  on,  the 
abdominal  walls  became  rigid,  and  most  marked  tenderness  was  always 
felt  to  the  right  of  the  umbilicus.  Considerable  improvement  took  place 
under  careful  feeding,  but  any  excess  in  the  diet  increased  the  sickness. 
The  bowels  opened  only  every  second  or  third  day.  Death  resulted  from 
perforation,  four  and  a  half  months  after  the  bowel  was  incarcerated.  At 
the  post  mortem  a  marked  contraction  of  the  ileum  was  found  about  four 
feet  from  the  caecum ;  the  distended  bowel  above  measured  four  and  a 
quarter  inches  in  circximference,  but  at  this  point  it  was  suddenly  reduced 
to  an  inch  and  a  half.  At  the  seat  of  contraction  the  calibre  of  the 
bowel  was  seven-eighths  of  an  inch,  and  the  part  showed  extensive  ulcera- 
tion, with  thickening  and  cicatrisation  of  the  mucous  membrane  involving 
the  whole  circumference.  (G.  N.  Pitt,  '  Trans.  Path.  Soc.  Lond.'  1891, 
vol.  xlii.  p.  119.) 

Still  rarer  causes  of  stricture  are  such  as  arise  from  some 
form  of  traumatism.  Thus  a  foreign  body  becoming  impacted 
gives  rise  to  ulceration,  and  this,  if  repair  subsequently  takes 
place,  may  lead  to  stricture.  A  blow  on  the  abdomen,  causing 
contusion  of  the  intestine,  may  give  rise  to  some  chronic  in- 
flammatory mischief  which  ends  in  a  narrowing  of  the  canal. 
Treves  ^  quotes  two  instances — one  where  the  patient  was 
ridden  over,  and  one  where  a  blow  was  received  upon  the 
abdomen.  In  the  former  case  symptoms  of  obstruction  came 
on  three  months  after  the  accident,  and  in  the  latter,  four 
months.  Mygind  '^  reports  a  case  of  stricture  the  result  of  a 
blow  upon  the  abdomen.  Successful  excision  was  performed 
six  months  after  the  receipt  of  the  original  injury. 

Frequently  in  cases  of  so-called  simple  stricture  it  is 
not  possible  to  ascribe  any  definite  cause.  It  is  more  than 
likely,  however,  that  some  ulceration  insufficient  to  cause 
S3  mptoms  has  preceded  the  formation  of  cicatricial  tissue. 
Whether  chronic  enteritis,  like  chronic  urethritis,  can  cause 
stricture  is  unknown. 

Case  LXXXV. — Simple  stricture  of  the  small  intestine  at  junction 
of  jejunum  and  ileum  :  enter oplasty.     Recovery. 
A  woman  aged  48  years  was  admitted  into  the  Great  Northern  Hos- 
pital.    She  stated  she  had  never  had  typhoid  fever  or  dysentery.     About 
three  months  ago,  she  was  suddenly  seized  with  pain  in  the  abdomen  after 
a  cup  of  tea,  and  was  treated  for  dyspepsia.     Ever  since  that  attack  she 

'  Page  265. 

■  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  ill.  C--  66. 


STIilCrrifK  .",!)7 

had  litid  violent  griping  pains  from  time  to  time.  A  fortnight  before 
admission  she  noticed  her  abdomen  swollen.  She  had  been  sick  several 
times.  The  bowels  had  acted  badly,  the  motions  being  loose  and  scanty. 
For  some  time  she  had  been  losing  flesh.  On  admission  to  hospital  the 
abdomen  was  found  to  be  considerably  distended,  principally  over  the 
lower  part.  It  was  resonant  all  over  ;  there  was  no  fluid  in  the  flanks ; 
deep  palpation  excited  peristaltic  action,  and  the  distended  coils  of  intes- 
tine stood  out  very  distinctly  through  the  abdominal  walls.  A  good  deal 
of  gurgling  could  be  heard  and  felt.  The  temperature  was  normal,  and 
the  pulse  was  rather  rapid  and  feeble  ;  the  urine  was  scanty,  loaded  with 
urates,  high  coloured ;  no  albumen.  The  face  was  pinched.  She  was 
greatly  emaciated  ;  complained  of  a  good  deal  of  griping  pain  during  the 
night.  The  bowels  were  open,  the  motions  being  loose,  but  containing 
neither  blood  nor  slime.  Laparotomy  was  performed.  A  stricture  was 
found  at  the  junction  of  the  jejunum  and  ileum,  and  treated  successfully 
by  enterojilasty,  an  operation  similar  in  its  performance  to  that  of  pyloro- 
plasty.     (AUingham,  'Lancet,'  1891,  vol.  i.  p.  1551.) 

As  a  last  cause  of  stricture,  brief  reference  may  be  made 
to  that  which  apparently  owes  its  origin  to  some  congenital 
defect,  either  the  result  of  disease  during  fcetal  life  or  of  some 
malformation.  A  congenital  origin  of  a  stricture  is  probable 
in  cases  where  the  symptoms  develop  early.  Eolleston  showed 
a  specimen  at  the  Pathological  Society  of  London,'  which  he 
believed  to  be  the  result  of  maldevelopment.  Stenosis  of  the 
jejunum  was  found  about  two  feet  from  the  duodenum  ;  two 
other  strictures  also  existed.  From  the  strictures  appearing 
like  membranous  diaphragms,  and  there  being  no  evidence  of 
disease,  it  was  thought  they  might  possibly  be  due  to  some 
maldevelopment  of  the  valvulae  conniventes. 

The  nature  of  the  stricture  and  its  patholor/ical  sequels. — The 
kind  of  stricture  is  mostly  determined  by  the  character  of  the 
ulcer  which  preceded  it.  The  deeper  and  wider  the  process 
of  ulceration,  and  the  more  completely  circumferential  its 
extent,  the  more  seriously  obstructive  becomes  the  subsequent 
cicatrix.  In  some  instances  the  stricture  is  so  narrow  in  its 
longitudinal  involvement  of  the  bowel,  that  externally  it  has 
the  appearance  as  if  constricted  by  a  string  tied  tightly  around 
it.  In  other  cases  an  inch  or  more  of  the  calibre  of  the  canal 
is  narrowed.  In  a  case  of  Fagge's,  quoted  by  Pitt,  where 
stricture  followed  upon  a  strangulated  hernia,  an  inch  and  a 

'   Trans.  1891,  vol.  xHi.  p.  122. 


398  THE   JEJUNUM   AND    ILEUM 

half  of  the  gut  was  narroweJ.  Its  coats  were  thickened  by 
hard  white  cicatricial  tissue.  The  mucous  membrane  was 
almost  devoid  of  villi. 

The  effect  of  obstruction  at  any  point  is  to  cause  dilatation 
of  the  canal  above,  and  hypertrophy  of  its  muscular  walls. 
These  changes  are  most  marked  in  the  immediate  neighbour- 
hood of  the  contraction,  becoming  less  so  as  the  more  distant 
parts  are  reached.  In  most  cases  the  dilatation  is  uniform  ; 
in  others,  however,  a  pouch  or  saccule  is  formed  in  which, 
either  as  a  cause  or  as  a  consequence,  a  foreign  body  such 
as  a  fruit  stone  is  frequently  found.  The  mucous  membrane 
above  the  stricture  is  often  found  ulcerated,  and  should  the 
patient  live  long  enough  and  the  process  of  ulceration  continue, 
there  is  the  possibility  of  perforation,  with  its  various  compli- 
cations of  adhesions,  abscesses,  fistulse,  or  more  extensive 
inflammation. 

Symptoms. — From  whatever  cause  produced,  the  symptoms 
connected  with  stricture  of  the  bowel  are  much  the  same. 
Differences  will  naturally  exist  in  the  early  history  of  the  case, 
as  for  instance  where  tubercular  ulceration  has  been  the  cause 
of  antecedent  diarrhoea ;  or  strangulated  hernia  existed ;  or 
some  injury  has  been  received  ;  but  when  once  cicatricial  con- 
traction has  definitely  set  in,  the  symptoms  in  every  case  become 
practically  indistin  guishable. 

The  onset  of  the  symptoms  varies.  In  some  cases  the 
progress  of  the  disease  is  marked  simply  by  a  vague  sense  of 
intestinal  discomfort  with  slight  pains  which  come  and  go ; 
with  loss  of  flesh,  and  increasing  weakness.  In  other  cases 
the  earliest  symptoms  of  intestinal  trouble  are  those  indicative 
of  acute  obstruction.  There  is  persistent  vomiting,  obstipation, 
with  increasing  distension  of  the  abdomen,  all  of  which  indicate 
a  complete  blockage  of  the  bowel. 

The  symptoms  therefore  are  largely  dependent  upon  the 
amount  of  obstruction  to  which  the  stricture  gives  lise. 
When  symptoms  manifest  themselves  at  a  period  prior  to  any 
marked  contraction  of  the  calibre  of  the  canal,  they  usually 
arise  from  some  temporary  blockage  of  the  passage.  In  such 
cases  the  patient  is  seized  with  vomiting  and  griping  pain, 
which  soon  disappear  as  the  temporary  obstacle  is  passed  on. 
These  attack?,  however,  reappear,  and   that  with  increasing 


STRICTURE  399 

frequency  as  the  stricture  contracts  and  the  canal  becomes 
narrower  in  calibre. 

This  temporary  blocking  of  the  canal  at  an  early  stage  of 
the  disease  usually  owes  its  origin  to  the  existence  of  some 
indigestible  material  in  the  bowel— such  for  instance  as  fruit 
stones,  fruit  skins,  &c. — or  to  a  too  solid  condition  of  the  fiieces. 
It  not  infrequently  happens  that  the  patient  becomes  conscious 
of  the  fact  that  any  indiscretion  in  diet,  or  the  consumption 
of  certain  indigestible  substances,  is  certain  to  be  followed  in 
the  course  of  a  few  days  by  the  onset  of  an  attack ;  and,  on  the 
other  hand,  a  careful  selection  of  foods  retards  the  frequency 
with  which  these  attacks  of  griping  pains  recur. 

The  early  attacks  may  be  short,  but  as  the  tightness  of  the 
stricture  increases  they  become  prolonged.  The  pains  become 
more  acute  in  character,  and  resemble  severe  attacks  of  colic. 
Unless  relief  soon  follows,  the  abdomen  begins  to  distend,  and 
the  peristaltic  movements  of  the  bowel  may  become  visible 
through  the  parietes,  especially  during  the  paroxysms  of  pain. 
Persistence  of  the  obstruction  leads  to  all  the  symptoms 
which  usually  follow  upon  complete  obstruction  arising  from 
other  causes. 

The  condition  of  the  bowels  varies  ;  in  many  instances 
there  is  constipation,  in  others  the  motions  are  loose.  The 
abdomen  is  not  usually  painful  on  palpation,  but  a  sense  of 
gurgling  is  often  detected  both  by  the  ear  and  the  hand. 

If  death  is  not  brougiit  about  by  an  acute  attack  of 
obstruction  which  remains  unrelieved,  it  usually  results  sooner 
or  later  from  emaciation  and  exhaustion.  Such  possible 
complications  as  perforation  above  the  seat  of  stricture 
may  cause  death  at  any  period  of  the  disease  from  acute  peri- 
tonitis. 

There  are  eases  where  no  symptoms  have  existed  prior  to 
those  associated  with  a  sudden  and  complete  blockage  of  the 
strictured  part.  In  these  cases  the  symptoms  are  similar  to 
those  met  with  in  other  cases  of  acute  obstruction,  and  become 
therefore  indistinguishable  from  those  the  result  of  internal 
strangulation,  volvulus,  and  other  such  like  causes.  Sudden 
pain  sets  in,  which,  while  more  or  less  continuous,  is  frequently 
increased  by  paroxysmal  attacks  :  vomiting  proves  incessant, 
becoming  feculent  in  the  course  of  a  few  days :  neither  faeces 


400  THE   JEJUNUM   AND    ILEUM 

nor  flatus  is  passed  :  meteorism  soon  makes  its  appearance  ; 
and  death  ensues  usually  within  a  week. 

These  acute  cases  owe  their  origin  to  the  same  cause  which 
gives  rise  to  slight  and  temporary  attacks  in  cases  where  the 
stricture  has  not  become  specially  tight.  Instead  of  the  foreign 
body  or  the  mass  of  faeces  becoming  loosened,  dislodged,  and 
passed,  it  remains  impacted  and  permanently  blocks  the 
narrowed  passage. 

It  occasionally  happens  that  the  patient  is  suddenly  relieved 
by  the  passage  of  a  copious  motion.  If  after  such  relief  acute 
symptoms  immediately  set  in,  the  probability  is  that  perfora- 
tion of  the  bowel  above  the  seat  of  stricture  has  taken  place. 
Without,  however,  the  sudden  onset  of  such  grave  symptoms, 
it  may  be  assumed  that  some  portion  of  the  obstruction  has 
given  way  and  allowed  the  block  to  be  dislodged  and  passed  on. 

Treatment. — The  organic  nature  of  the  obstruction  renders 
any  conservative  measures  useless,  when  treatment  is  con- 
sidered from  a  curative  point  of  view.  It  is  possible,  however, 
to  give  considerable  relief  in  many  cases  by  a  careful  regula- 
tion of  the  diet.  It  has  already  been  stated  that  patients 
themselves  frequently  find  that  certain  foods,  especially  those 
of  an  indigestible  nature,  are  liable  in  the  course  of  a  few  hours 
after  ingestion  to  provoke  an  attack  of  pain  and  vomiting. 
Hence  such  indications  should  be  taken  as  a  good  guide 
regarding  the  conservative  treatment  to  be  followed  out. 

When,  however,  symptoms  of  complete  and  permanent 
obstruction  manifest  themselves,  little  or  no  hope  can  be 
looked  for  by  delay. 

The  simplest  and  in  one  sense  the  safest  operative  measure 
the  surgeon  can  adopt  is  merely  to  relieve  the  distended  bowel 
by  making  an  abdominal  incision  and  opening  the  first  dis- 
tended loop  which  presents.  The  establishment  of  an  artificial 
anus  will,  if  the  bowel  has  not  lost  its  contractile  power 
through  prolonged  over-distension,  end  in  the  copious  ejection 
of  its  contents,  with  immediate  relief  to  the  patient's  sufferings. 
This  measure,  however,  can  only  be  considered  temporary, 
and  a  subsequent  operation  will  be  necessary  to  deal  with  the 
stricture. 

Two  ways  of  dealing  with  the  stricture  have  been  success- 
fully carried  out.     The  most  radical,  as  illustrated  by  Garro's. 


GALL-STONES  401 

and  Mygind's  cases,  is  to  excise  it  and  unite  the  ends.  This, 
when  effected  by  Murphy's  button,  can  be  very  rapidly  ex- 
ecuted. The  second  method  is  to  adopt  the  plan  successfully 
followed  by  Pean '  and  by  Allingham,^  of  performing  what  is 
correctly  termed  *  enteroplasty,'  from  its  resemblance  to  the 
Heineke-Mikulicz  operation  of  pyloroplasty.  The  stricture 
is  divided  longitudinally  and  the  edges  of  the  incision  united 
transversely. 

The  rapidity  with  which  either  of  these  methods  can  be 
carried  out  renders  them  possible  as  primary  measures  after 
opening  the  abdomen  in  the  middle  line,  below  the  umbilicus. 
If  for  any  reason  the  means  are  not  at  the  surgeon's  disposal 
to  render  the  operation  a  rapid  and  safe  one,  he  will  be  wiser 
to  defer  the  radical  treatment  of  the  stricture  for  a  secondary 
operation,  and  be  satisfied  with  a  fjEcal  fistula  for  the  time  being. 

The  usual  after  treatment  should  be  adopted,  nutrient 
enemata  taking  the  place  of  nourishment  by  the  mouth  for 
the  first  few  days. 


CHAPTER   XLVIII 

6.    GALL-STONES.       INTESTINAL    CONCRETIONS 

These  occasional  contents  of  the  bowel  have  already  been 
briefly  alluded  to  under  the  heading  of  '  Foreign  bodies,'  which 
in  a  sense  they  practically  are.  But  there  are  many  points 
about  them  sufficiently  distinctive  to  render  a  separate  con- 
sideration necessary. 

Gall-stones. — Disease  the  result  of  gall-stones  in  the  intes- 
tine more  frequently  occurs  in  females  than  in  males,  in  the 
proportion  of  four  to  one,  and  rarely  manifests  itself  before 
middle  age.  In  sixteen  cases  collected  by  Treves,^  the  average 
age  was  57  years.  In  only  one  instance  was  the  patient  under 
40  years,  and  in  that  the  woman's  age  was  27  years.  The 
oldest  woman  was  78  years. 

The  stone  finds  its  way  into  the  bowel  either  by  the  com- 
mon bile  duct  or  by  ulceration  into  the  third  part  of  the 
duodenum,  usually  direct  from  the  fundus  of  the  gall  bladder. 

'  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  iii,  C  — 69. 
2  See  Case  LXXXV.  p.  39G.  '  Pa-e  326. 

D  D 


402  THE   JEJUNUM   AND    ILEUM 

Probably  in  the  majority  of  instances  where  intestinal  mischief 
is  subsequently  set  up,  the  stone  has  been  too  large  to  pass 
by  the  duct,  and  has  found  its  way  into  the  bowel  direct  by 
ulceration. 

Mayo  Eobson '  has  classed  under  four  heads  the  ways  in 
which  gall-stones  may  give  rise  to  obstruction. 

(1)  The  paralytic  form,  dependent  on  local  peritonitis  in 
the  region  of  the  gall  bladder. 

(2)  Volvulus  of  the  small  intestine  dependent  either  on  the 
violence  of  the  colic  caused  by  an  attack  of  cholelithiasis,  or 
on  the  contortions  induced  by  the  pissage  of  a  large  concretion 
through  the  small  intestine. 

(3)  Mechanical  obstruction  due  to  the  passage  of  a  large 
concretion  through  the  small  intestine. 

(4)  Obstruction  depending  on  adhesions  or  on  stricture  the 
result  of  past  gall-stone  attacks,  or  of  healing  fistulse. 

The  form  of  obstruction  most  frequently  met  with  is  that 
classed  as  (3).  The  obstruction  is  mechanical,  and  due  to  the 
blocking  of  the  bowel  at  some  point  by  the  gall-stone  becoming 
impacted.  The  neighbourhood  of  the  ileo-csecal  valve  in  the 
ileum  is  the  most  common  seat  of  obstruction. 

The  stone  which  becomes  impacted  is  usually  a  large  one 
but  size  does  not  appear  to  be  the  sole  determining  factor, 
for  stones  quite  as  large  as  any  which  have  caused  serious 
symptoms  have  been  passed  without  material  trouble.  Tt  is 
possible  tha,t  in  not  a  few  instances  either  the  state  of  the 
contents  of  the  bowel  or  sluggishness  in  its  peristaltic  action 
causes  the  calculus  to  become  coated  with  faecal  concretion, 
and  hence  its  size  so  augmented  that  obstruction  ensues.  It 
is  often  found  that  the  stone,  when  passed  or  removed  by 
operation,  is  surrounded  with  a  considerable  quantity  of  fsecal 
material. 

As  illustrating  some  of  the  sizes  of  stones  met  with,  one 
shown  by  Marshall  ^  at  the  Glasgow  Pathological  and  Clinical 
Society  may  be  instanced.  It  weighed  4  drachms  3  grains, 
and  measured  If  inch  in  length,  and  3^  inches  in  circum- 
ference at  its  thickest  part.  The  stone  was  passed  per  rectum. 
H.  E.  Clark,^  before  the  same  Society,  showed  one  which  weighed 

'  Brit.  Med.  Journ.  1895,  vol.  i.  p.  194. 

2  Trans.  1893,  vol.  iv.  p.  227.  ^  Ibid.  1891,  vol.  iii.  p.  65. 


GALL-STONES  403 

3^  drachms  and  measured  1^  inch  in  length,  1  inch  in  breadth, 
and  3f  inches  in  circumference.  It  had  caused  intestinal 
obstruction,  and  was  removed  by  enterotomy.  Taylor  •  figures 
in  the  '  Lancet '  a  stone  which  weighed  1^  oz.,  was  4|  inches 
in  circumference  and  2  inches  in  length.  It  was  successfully 
removed  by  enterotomy.  For  exceptional  examples  of  much 
larger  stones,  Murchison's  well-known  work  on  Diseases  of  the 
Liver  should  be  consulted. 

Symptoms. — Obstruction  from  gall-stones  adds  still  another 
cause  to  the  many  which  give  rise  to  acute  symptoms  without 
often  indicating  the  true  nature  of  the  cause. 

In  the  cases  which  fall  under  the  first  heading  of  Mayo 
Eobson's  classification  there  will  be,  in  addition  to  the  sym- 
ptoms of  acute  obstruction,  pain  and  tenderness  about  the 
region  of  the  gall  bladder,  due  to  the  local  peritonitis  set  up 
in  that  part. 

In  the  more  frequently  met  with  class  of  cases  of  mechani- 
cal obstruction,  the  symptoms  may  commence  suddenly  and 
in  a  way  quite  similar  to  acute  obstruction  from  other  causes. 
The  patient  while  in  perfect  health  is  suddenly  seized  with 
violent  abdominal  pain,  vomits  incessantly,  and  passes  neither 
flatus  nor  faeces.  The  vomit,  at  first  bilious,  becomes  in  the 
course  of  a  few  days  faecal.  The  patient  soon  shows  the  cha- 
racteristic, drawn,  sunken,  anxious  face.  The  abdomen,  not 
tender  or  distended  at  first,  may  become  so.  A  dry  tongue 
with  parched  mouth,  and  thirst  causes  much  distress  ;  and  if 
the  obstruction  is  to  prove  fatal,  peritonitis  may  supervene 
and  the  patient  die  of  exhaustion. 

The  early  history  of  the  case  sometimes  affords  a  clue 
in  these  cases  of  mechanical  obstruction.  Thus  the  patient 
may  have  had  previous  attacks  of  biliary  colic  accompanied 
with  jaundice  and  the  passage  of  gall-stones  ;  or  there  may 
have  been  some  tenderness  and  pain  in  the  region  of  the  gall 
bladder,  due  to  the  process  of  ulceration  taking  place  there 
while  the  stone  found  its  way  into  the  duodenum.  In  very 
many  cases,  however,  no  such  history  will  be  forthcoming,  for 
large  stones  will  sometimes  pass  directly  from  the  gall  bladder 
into  the  duodenum  without  causing  any  manifest  disturbance. 

In  some  cases  gall-stones  remain  for  a  considerable  time 

'  Lancet,  1S95,  vol.  i.  p.  867. 


404  THE    JEJUNUM   AND   ILEUM 

in  the  bowel,  giving  rise  to  intermittent  attacks  of  obstruction, 
and  producing  symptoms  suggestive  of  stricture.  In  Taylor's 
case,  above  quoted,  the  patient  suffered  for  twenty- six  days  from 
symptoms  of  variable  acuteness.  On  the  twenty-seventh  day 
obstruction  was  complete  and  faecal  vomiting  appeared. 

Physical  examination  of  the  abdomen  does  not  usually  afford 
much  information.  It  is  possible  sometimes,  however,  with  the 
patient  under  an  anaesthetic,  to  feel  the  stone.  Such  was  the 
case  in  a  patient  of  Eve's, ^  in  whom  he  was  able  to  detect 
the  calculus  in  the  left  iliac  fossa. 

Prognosis. — Possibly  there  is  no  cause  which  gives  rise  to 
typical  symptoms  of  acute  obstruction  that  can  be  considered 
so  hopeful  in  its  ultimate  issue  as  that  of  an  impacted  gall- 
stone. The  most  severe  symptoms  may  manifest  themselves, 
but  these  may  completely  subside,  the  patient  pass  the 
gall-stone  per  anmn,  and  perfect  recovery  ensue.  Numerous 
cases  are  reported  in  proof  of  this.  To  instance  only  two. 
T.  K.  Monro  ^  showed  a  specimen  at  the  Glasgow  Medico- 
Chirurgical  Society  of  a  stone  which  had  been  passed_per  rectum. 
The  patient  was  taken  suddenly  ill  after  eating  a  hearty  supper. 
When  seen  the  following  day,  she  was  found  to  be  suffering 
from  severe  sickness  and  vomiting  with  great  abdominal 
pain,  the  symptoms  suggesting  acute  obstruction.  They  all, 
however,  gradually  disappeared  and  the  patient  passed  the 
calculus  ;  no  further  trouble  followed.  In  the  other  instance, 
a  case  quoted  by  Hutchinson,^  the  symptoms  were  of  such 
extreme  severity  that  on  the  sixth  day  all  hope  was  abandoned 
and  it  was  expected  the  woman  would  die  that  night.  The 
following  morning,  however,  improvement  set  in,  and  on  the 
next  day  she  voided  a  gall-stone  which  measured  an  inch  in 
diameter.  Complete  recovery  followed.  Eecovery  may  even 
take  place  after  the  appearance  of  faecal  vomiting.  Murchison  * 
instances  a  case  where  this  symptom  had  lasted  for  upwards 
of  three  weeks. 

While,  however,  there  is  the  possibility  of  recovery,  there 
appears,  judging  by  Treves's  statistics,''  the  greater  probabihty 

'   Brit.  Med.  Joitrn.  1895,  vol.  i.  p.  195. 

-  Glascjoio  Medical  Journal,  1895,  vol.  xliii.  p.  447. 

^  Archives  of  Surgery,  1892,  vol.  iii.  p.  9. 

■*  Lectures  on  Diseases  of  the  Liver,  2ncl  edit.  p.  494.  ^  Page  335. 


Ci  ALL-STONES  405 

of  death.  Thus  out  of  twenty  cases  where  definite  and  severe 
symptoms  of  obstruction  existed,  six  recovered  and  fourteen 
died. 

Unfortunately  there  are  no  symptoms  which  enable  one  to 
state  in  any  case  whether  or  not  the  stone  will  move  on.  It 
is  always  reasonable  to  entertain  the  hope  of  nature  effecting 
a  cure  unaided ;  but  the  great  difficulty  is  to  say  how  long 
such  a  hope  is  to  be  entertained;  how  long,  in  short,  should 
the  symptoms  be  allowed  to  continue  before  operative  inter- 
vention is  permitted. 

Treatment. — It  has  already  been  pointed  out  that  in  very 
many  instances  obstruction  from  gall-stone  will  not  be  dia- 
gnosed until  laparotomy  is  performed.  It  must  be  assumed 
here,  however,  that  for  the  sake  of  discussion  we  are  dealing 
with  cases  where  gall-stones  are  known  to  be  the  cause  of  the 
symptoms. 

Treatment  should  in  the  first  place  consist  of  purely 
conservative  measures.  An  anresthetic  should  be  given,  large 
quantities  of  fluid  injected  into  the  rectum  and  colon,  and 
abdominal  taxis  practised. 

Following  upon  this  some  belladonna  and  opium  should  be 
administered,  all  nourishment  withheld  from  the  stomach,  and 
the  patient  kept  at  rest. 

In  almost  every  instance  the  stone  at  an  early  stage  of 
the  attack  is  capable  of  being  dislodged  from  its  seat.  It  is 
always  possible  therefore  that  these  energetic  measures  may 
prove  sufficient,  and  within  a  short  time  of  their  performance 
the  poiient  may  pass  flatus  and  later  a  copious  stool.  The 
stone  occasionally  gets  stopped  just  above  the  sphincter,  and 
gives  rise  to  considerable  inconvenience  and  pain  in  its  final 
ejection  through  the  anus. 

Should  these  measures  fail  to  give  relief,  the  question  of 
delay  or  the  immediate  performance  of  enterotomy  has  to  be 
considered. 

If  the  results  of  operations  were  more  successful  than  they 
at  present  seem  to  be,  not  much  difficulty  would  exist  in  de- 
ciding the  proper  course  to  pursue.  The  fact,  however,  that 
statistics  show  but  little  preference  for  interference  over  non- 
interference renders  the  matter  far  from  being  an  easy  one 
to  settle.     Treves  gives  six  recoveries  out  of  twenty  where  no 


406  THE   JEJUNUM    AND   ILEUM 

operation  was  performed,  and  Eve/  in  January  1895,  stated 
that  since  1889  eighteen  cases  had  been  recorded  which  had 
been  operated  upon,  and  nine  had  recovered.  Terrillon  ^  has 
collected  twenty-three  similar  cases,  seven  of  which  were  suc- 
cessful after  operation. 

By  contrasting  the  percentage  recoveries  it  is  seen  that 
where  no  operation  was  performed  there  were  30  per  cent.,  and 
where  operated  upon,  50  per  cent,  in  one  list  and  30*4  per 
cent,  in  the  other.  It  is  quite  possible  that  these  statistics 
are  very  fairly  comparable,  because  in  both  instances  of 
operation  and  non-operation  it  is  much  more  likely  that 
natural  recoveries  and  recoveries  after  operation  would  be 
published  than  the  deaths  attributable  either  to  the  one  or  to 
the  other.  The  difference,  however,  cannot  be  considered  suffi- 
ciently great  to  settle  the  question  in  favour  either  of  delay  or 
operation. 

Irrespective  of  statistics,  cogent  factors  which  need  to  be 
taken  into  account  in  any  endeavour  to  decide  upon  the  proper 
course  to  pursue  are  the  circumstances  attending  the  immediate 
surroundings  of  the  patient.  In  the  case  of  hospital  patients 
the  conditions  would  be  practically  the  same  as  in  the  case  of 
patients  in  their  own  private  homes,  where  nature  is  left  to 
her  own  unaided  efforts.  They  would,  however,  be  markedly 
different  in  the  case  of  operations  performed  in  these  respective 
places.  Herein  therefore  probably  exists  the  solution  of  the 
difficulty.  If  the  conditions  are  such  as  will  permit  of  the 
operation  being  performed  with  all  the  most  approved  requi- 
sites, and  by  one  sufficiently  experienced,  then  there  can  be  but 
little  doubt  that  the  best  results  will,  on  the  whole,  be  attained 
by  the  performance  of  enterotomy.  Failing,  however,  both 
these  essentials,  the  practitioner  will  act  more  wisely  in  refrain- 
ing from  operation. 

Operation. — In  performing  entero-lithotomy,  the  usual  pre- 
cautions must  be  taken  in  the  preliminary  process  of  opening 
the  abdomen.  The  parietal  incision  should  be  in  the  middle 
line,  below  the  umbilicus. 

The  lower  part  of  the  ileum  should  first  be  sought  for  as 
being  the   probable  seat  of  the  calculus.     When  found,  an 

^  Brit.  Med.  Journ.  1895,  vol.  i.  p.  195.  ...  _     -. 

^  Anmial  of  the  Universal  Medical  Sciences,  1894,  vol.  iii.  C— 27. 


GALL-STONES  -      407 

endeavour  should  be  made  by  gentle  external  manipulation  to 
squeeze  the  stone  on,  and  if  possible  get  it  through  the  ileo- 
csecal  valve  into  the  cfecum.  Glutton  '  reports  a  case  in  which 
he  successfully  managed  to  do  this.  The  stone  was  situated 
about  eight  inches  from  the  valve.  Five  days  after  the  operation 
the  stone  was  passed,  when  it  was  found  to  measure  1^  inch 
in  length,  1  inch  in  its  largest  diameter,  and  3f^,j  inches  in 
its  largest  circumference.  If  it  proves  possible  to  thus  effect 
dislodgment,  nothing  further  remains  to  be  done  except  to 
close  the  abdomen. 

If  the  stone  cannot  be  displaced,  the  bowel  should,  if 
possible,  be  drawn  out  of  the  abdomen  and  incised  in  a  longi- 
tudinal direction  over  the  stone,  and  the  latter  extracted. 
Prior  to  opening  the  bowel  every  possible  precaution  must  be 
taken,  by  the  proper  application  around  of  sponge  cloths,  &c., 
to  prevent  any  contamination  of  the  peritoneum  by  the  con- 
tents of  the  intestine.  In  many  instances  death  has  resulted 
from  septic  peritonitis. 

After  the  stone  is  withdrawn,  the  opportunity  should  be 
taken,  which  the  opening  in  the  gut  affords,  of  allowing  the 
escape  of  any  fseces  or  flatus  which  may  be  overdistending 
the  bowel  above.  The  edges  of  the  mucous  membrane  should 
then  be  stitched  together  by  a  continuous  suture,  and  the 
external  coats  united  by  a  series  of  Lembert  stitches.  Should 
there  be  any  sus^Dicion  of  escape  of  fsecal  material  into  the 
peritoneal  cavity,  it  should  be  freely  flushed  and  sponged  dry 
before  closing  the  parietal  wound. 

As  possible  contingencies  to  be  encountered  and  dealt 
with,  the  surgeon  may  have  to  consider  the  propriety  of  ex- 
cising the  area  of  impaction  or  stitching  the  bowel  orifice 
to  the  abdominal  wound  and  so  forming  a  temporary  fsecal 
fistula.  One  of  these  courses  must  be  pursued  when,  from 
ulceration  or  other  damage  to  the  bowel  wall  at  the  seat  of  im- 
paction, the  parts  are  not  in  a  condition  to  be  safely  stitched 
up  and  returned.  Adhesions  may  have  to  be  separated ;  and 
the  twisting  of  a  coil  undone  which,  as  already  pointed  out,  is 
sometimes  associated  with  a  gall-stone. 

'   Trans.  Clin.  Soc.  Lend.  1888,  vol.  xxi.  p.  99. 


408 


THE   JEJUNUM   AND   ILEUM 


Table  of  Successful  Cases  of  Enter o -lithotomy  for  impacted  Gall-stones 
causing  Intestinal  Obstruction,  from  1891  to  1895  inclusive 


Time  intervening 

Operator 

Nature  of 
Obstruction 

between  onset  of 

symptoms  and 

operation 

Nature  of 
Operation 

Reference 

Thiriar 

11  days 

Bntero-lithotomy 

Revue  de  Chirurg. 
1891,  p.  403 

Bruce  Clarke 

Lancet,  1893,  i. 
1196 

Kbrte  . 

7  days 

Entero-lithotomy 

Brit.  Med.  Journ. 
Epitome,  1894, 

(This 

author  refers  to  3 
successfully) 

other  cases,  in  2  of 

which  he  operated 

i.  50.  See  also 
Berl.  klin.  Wo- 
Chen.  1893,  p. 
690 

W.  A.  Lane 

Impacted  in  jeju- 
num 

5  days 

Entero-lithotomy 

Lancet,  1894,  ii. 
882 

Terrillon     . 

Not  stated 

Ann.  Univ.  Med. 

(This 

author  has  coUecte 
successful) 

d  23  similar  cases, 

of  which  7  were 

Sci.  1894,  iii. 
C— 27 

H.  Vernon  . 

Impacted  iu  ileum 

Not  given 

Entero-lithotomy 

Brit.  Med  Journ. 
1894,  ii.  1179 

Mayo  Robson 

» 

Trans.Royal  Med.- 
Chir.  Soc.  Lond. 
1895,     Ixxviii. 
117 

„     (2nd  case) 

„ 

Ibid. 

W.  C.  E.  Taylor  . 

Lower    part     of 

26  days  subacute 

Lancet,    1895,    i. 

ileum 

symptoms,  27th 
day  acute  with 
fsecal     vomit- 

867 

F.  Eve 

Lower     end     of 
ileum,  2    or   3 
inches       from 
ileo-ceecal  valve 

ing 

5  days 

" 

Trans.  Clin.  Soc. 
Lond.  1895, 
xxviii.  97 

Case  LXXXVI. — Gall-stone  causing  acute  intestinal  obstruction  : 
entero-lithotomy.     Recovery. 

A  woman  aged  54  years  was  admitted  into  Guy's  Hospital  on  Tuesday 
night,  April  24,  suffering  from  symptoms  of  acute  intestinal  obstruction, 
wHch  had  commenced  at  3  a.m.  on  Friday,  the  20th,  more  than  four  and  a 
half  days  previously.  From  the  commencement  of  the  attack  she  had  suf- 
fered from  very  severe  griping  pains  at  frequent  intervals,  from  vomiting, 
and  from  obstipation.  When  admitted  into  hospital,  the  abdomen  was 
distended,  very  tender  on  pressure,  and  a  distinct  thrill  could  be  felt  on 
percussion.  Vomit  not  faecal.  Her  past  history  was  that  for  the  last  three 
years  she  had  suffered  off  and  on  from  attacks  of  indigestion,  during  which 
she  experienced  much  distension  of  the  abdomen,  with  some  tenderness 
on  pressure.  Two  or  three  months  after  the  appearance  of  the  indigestion 
she  was  jaundiced  for  several  days.  There  had  never  been  any  particular 
pain  or  tenderness  in  the  region  of  the  gall  bladder.  Laparotomy  was 
performed  four  and  a  half  days  after  the  onset  of  the  symptoms.  A  gall- 
stone was  found  impacted  in  the  bowel,  about  eight  feet  from  the  duodenum. 
The  peritoneal  cavity  contained  a  quantity  of  turbid  fluid  tinged  with 


INTESTINAL   CONCRETIONS  403 

blood.  The  upper  part  of  the  jejnmim  was  very  much  distended;  the 
walls  of  the  bowel  were  deeply  injected  and  covered  with  lymph  where 
the  coils  approximated  each  other.  The  bowel  below  the  obstruction  was 
quite  empty.  The  stone  was  removed  through  an  incision  which  was 
afterwards  closed  with  horsehair.  Great  difficulty  was  experienced  in 
gettmg  the  distended  bowel  back  into  the  abdominal  cavity.  The  patient 
made  an  uninterrupted  recovery.  (W.  A.  Lane,  '  Lancet,'  1894,  vol.  ii. 
p.  382.) 

Intestinal  concretions  or  enteroliths. — It  is  rarely  that  these 
form  or  collect  in  the  small  intestine  sufficiently  to  give  rise 
to  obstruction.  They  are  much  more  frequently  met  with  in 
the  large  bowel.  When  present  in  the  former,  they  are  usually 
found  about  the  lower  end  of  the  ileum.  Treves  '  figures  a 
specimen  which  exists  in  St.  Thomas's  Hospital  Museum. 
The  small  intestine  is  almost  entirely  blocked  at  one  point  by 
a  dense  mass  of  magnesia  which  fills  the  gut  for  several 
inches.  Myles  ^  gives  the  details  of  a  casein  which  symptoms 
of  complete  intestinal  obstruction  were  produced  by  an  entero- 
lith impacted  in  the  ileum.  The  patient  had  suffered  fifteen 
years  before  from  hepatic  colic,  and  since  then  from  chronic 
constipation.  The  history  of  the  case  would  thus  seem  to  point 
to  the  calculus  being  possibly  biliary  in  its  origin  ;  and  as  no 
section  of  it  was  made,  the  question  of  its  being,  as  described, 
an  intestinal  concretion,  must  remain  somewhat  doubtful. 
Schroeder's  case,  given  in  detail  below,  is  an  interesting  example 
of  a  case  where  the  symptoms  which  followed  were  never 
sufficiently  acute  to  prove  fatal.  It  further  illustrates  the 
probable  way  in  which  many  of  these  calculi  are  formed — 
that  is,  by  the  free  and  prolonged  use  of  some  salt  or  mineral 
substance. 

Case  LXXXVII. — Intestinal  concretion  causing  prolonged  symjytoms 
of  obstinate  constipation. 
A  man  aged  53  years  had  suffered  for  twenty-three  years  from  agonising 
attacks  of  abdominal  colic,  obstinate  habitual  constipation,  hsemorrhoidal 
bleedings,  meteorism,  cardiac  palpitation,  and  headache.  During  the  last 
five  years  or  so  his  stools  had  been  occasionally  followed  by  spells  of  spas- 
modic abdominal  pain,  with  discharge  of  thready  or  flaky  mucus.  In  the 
course  of  such  an  attack  a  hard  foreign  body  was  discharged,  after  which 
the  patient  gradually  lost  all  his  symptoms.  The  foreign  body  proved  to  be 
a  friable,  bean-shaped,  pale  brown  calculus  measuring  three  and  a  half  by 

'  Page  339.  -  Brit.  Med.  Journ.  1891,  vol.  i.  p.  288. 


410  THE   JEJUNUM   AND   ILEUM 

one  and  a  half  centimetres,  and  weighing  62  grains.  It  was  composed  of 
a  thin  superficial  stratum  of  a  pale  brown  colour  and  a  thicker  greyish 
inner  layer,  with  a  small,  white,  central  nucleus.  The  concretion  con- 
sisted of  carbonate  and  phosphate  of  lime,  its  external  layer  containing  a 
large  proportion  of  red  oxide  of  iron.  The  presence  of  the  latter  constituent 
may  be  easily  explained  by  the  fact  that  five  years  previously  the  man 
had  been  treated  by  the  Marienbad-Kreuzbrunnen  mineral  water,  contain^ 
ing  chalybeates  in  the  form  of  carbonate  of  iron.  (Von  Schroeder, '  Annual 
of  the  Universal  Medical  Sciences,'  1892,  vol.  i.  D — 21.) 


CHAPTER   XLIX 

7.    TUMOURS    OF    THE    BOWEL   WALL.       INNOCENT    AND    MALIGNANT 

Neither  the  jejunum  nor  the  ileum  is  a  frequent  seat  for  the 
development  of  new  growths.  Such  as  do  arise  affect  mostly 
the  internal  coats,  and  by  their  increase  in  size  tend  to 
obstruct  the  canal.  It  is  usual  to  consider  these  neoplasms 
under  the  common  classification  of  innocent  and  malignant. 

Innocent. — Fibromata.  —  Tumours  composed  chiefly  of 
fibrous  tissue  develop  in  the  submucous  coat  and  then  project 
into  the  canal,  forming  one  of  the  kinds  of  polypus  which  are 
occasionally  met  with  in  the  small  intestine.  According  to 
Leichtenstern/  intestinal  polypi  are  most  frequently  met  with 
in  the  lowest  part  of  the  ileum,  hardly  ever  in  the  upper  part, 
and  only  occasionally  in  the  jejunum.  Taking  the  intestine 
as  a  whole,  their  commonest  seat  is  in  the  rectum,  where 
they  will  be  again  referred  to.  Hale  White  ^  records  the  case 
of  a  polypus  in  the  upper  part  of  the  jejunum.  It  gave  rise 
to  intussusception  and  death. 

Myomata. — These  tumours,  composed  partly  of  unstriped 
muscle  tissue,  arise  from  the  muscular  coat  of  the  bowel, 
and  usually  take  the  form  of  polypus.  A  somewhat  unusual 
illustration  of  a  vascular  myoma  is  recorded  by  Mercer.^ 
A  patient  died  suddenly  in  twenty-four  hours  from  intesti- 
nal haemorrhage,  with  no  previous  symptoms.      At  the  post 

'  Ziemssen's  Cyclopcsclia,  vol.  vii.  p.  634. 

'-'  Trans.  Path.  Soc.  Lond.  1890,  vol.  xli.  p.  121. 

^  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  i.  D  -15. 


INNOCENT  TUMOURS  411 

mortem  a  vascular  myoma  ten  centimetres  in  diameter  was 
found  attached  by  a  pedicle  to  the  ileum ;  a  small  oval 
opening  in  the  mucous  lining  of  the  ileum  corresponded  to 
the  attachment  of  the  pedicle,  and  from  this  it  is  sujDXJOsed 
the  fatal  haemorrhage  occurred. 

Adenomata. — These  tumours,  glandular  in  structure,  arise 
from  Lieberkiihn's  follicles.  Like  the  two  preceding,  they 
form  polypi  which  project  into  the  bowel.  Tito-Carbone  ^  found 
an  adenoma  in  the  lower  part  of  the  jejunum,  between  the 
muscular  and  mucous  coats.  It  was  irregular  in  shape,  and 
measured  five  millimetres  in  diameter. 

lApomata. — Fatty  tumours  are  sometimes  found.  They 
develop  in  the  submucous  tissue,  and  are  frequently  multiple. 
They  rarely  cause  obstruction. 

Cysts. — These  probably  constitute  the  rarest  kind  of 
tumour  met  with  in  the  small  intestine.  Buchwald  ^  reports 
the  case  of  a  boy  who  died  of  obstruction.  At  the  post 
mortem  two  cysts  were  found  connected  with  the  walls  of  the 
jejunum.  Their  weight  had  caused  them  to  so  drag  upon  the 
gut  wall  that  the  canal  became  almost  occluded. 

The  various  kinds  of  innocent  tumours  do  not  give  rise 
to  any  symptoms  whereby  they  may  be  diagnosed.  If  they 
cause  obstruction  it  may  either  be  of  an  acute  or  a  chronic 
character.  Those  which  form  polypi  not  infrequently  induce 
intussusception.  In  such  cases  it  is  usual  to  find  the  polypus 
at  the  apex  of  the  intussusceptum. 

A  class  of  innocent  tumours  has  already  been  referred 
to  (see  page  202)  which,  solid  in  their  structure  and  often 
malignant  in  their  clinical  features,  possess  the  peculiar 
faculty  of  disappearance.  They  are  spoken  of  more  generally 
as  solid  tumours  of  the  abdomen  which  spontaneously  dis- 
appear. Their  actual  connections  are  unknown,  but  they 
appear  in  some  cases  to  be  intimately  connected  with  the 
intestines.  They  are  usually  ascribed  to  inflammation, 
although  the  evidences  are  not  always  in  support  of  such 
an  explanation.  Greig  Smith,^  who  has  carefully  considered 
the  possible  origin  of  these  tumours,  arrives  at  the  foUow- 

'  Annual  of  the  Universal  Medical  Scierices,  1891,  vol.  i.  D— 20. 

2  Ibid.  1888,  vol.  i.  p.  357. 

3  Trans.  Royal  Med.-Chir.  Soc.  Lond.  1894,  vol.  Ixxvii.  p.  139. 


412  THE   JEJUNUM   AND   ILEUM 

ing  conclusion  :  '  They  are  simply  aggregations  of  embryonic 
cells  and  tissues,  heajped  up  around  an  intestinal  perforation. 
The  perforation  is  minute  and  the  amount  of  escaping  fluid 
is  small,  so  that  the  cells  can  effectively  deal  with  it.  The 
perforation  remains  open  for  a  long  period  of  time,  and  the 
continued  demand  -for  new  cells  results  in  an  aggregation 
which  is  practically  a  tumour.' 

The  symptoms  to  which  these  tumours  give  rise  are  often 
of  an  obstructive  character  ;  and  the  sensation  which  they 
convey  to  the  touch  usually  suggests  sarcoma. 

Case  LXXXVIII. — Spontaneous  disappearance  of  a  solid  tumour  of  the 
intestines  causing  obstruction.  Enterostomy. 
A  young  man,  aged  25,  was  sent  to  the  Bristol  Infirmary  on  June  1, 
1889.  He  was  then  suffering  from  intestinal  obstruction.  Tlie  cause  of 
the  obstruction  was  found  on  operation  to  be  a  solid  tumour  as  large  as  a 
cocoanut,  occupying  the  left  iliac  region.  An  aspirator  needle  introduced 
into  the  growth  proved  it  to  be  solid.  Intestines  were  in  several  places 
adherent  to  it.  It  might  have  been  removed,  but  as  the  patient  was  ill 
from  the  obstruction,  and  sarcoma  was  diagnosed,  it  was  considered  ad- 
visable to  be  content  with  intestinal  evacuation  and  drainage.  Enterostomy 
was  performed  in  the  lower  ileum,  the  gut  being  fixed  in  the  median 
parietal  incision.  For  about  a  fortnight  all  the  fiBces  passed  through  the 
artificial  opening;  but  gradually  faeces,  increasing  in  amount,  appeared 
by  the  rectum.  When  the  abdomen  was  flat  the  tumour  caused  quite  a 
marked  and  localised  bulging  in  the  left  lower  abdomen,  and  was  easily 
palpable.  At  the  end  of  six  months  it  was  evident  that  the  intestinal 
passage  had  been  restored,  so  the  artificial  opening  was  closed  by  opera- 
tion. At  this  time  no  tumour  could  be  felt  through  the  parietes  ;  and  at 
the  time  of  operation  the  finger  inserted  into  the  abdomen  felt  only  adhe- 
sions, but  no  trace  of  tumour.  The  patient  rapidly  regained  strength  and 
put  on  flesh  ;  and  now,  after  four  and  a  half  years,  remains  quite  well. 
(J.  Greig  Smith,  '  Trans.  Eoyal  Med.-Chir.  Soc.  Lond.'  1894,  vol.  Ixxvii. 
p.  140.) 

Malignant  tumours. — Cancer,  whether  in  the  form  of 
carcinoma  or  sarcoma,  is  a  comparatively  rare  disease  of 
the  small  intestine.  Nevertheless  unmistakable  cases  occur, 
which  prove  that  the  bowel  may  be  affected  both  primarily 
and  secondarily. 

Carcinoma. — The  lining  cells  of  the  mucous  membrane  are 
of  the  columnar  type  of  epithelium.  Hence,  as  would  naturally 
be  expected,  columnar-celled  carcinoma  or  epithelioma  is  the 
form  most  frequently  met  with.      It  is  unfortunate  that  there 


CARCIXOxMA  413 

is  some  lack  of  uniformity  in  the  terms  applied.  Ransom  ' 
speaks  of  having  met  with  a  case  of  glandular  carcinoma, 
but  the  drawings  which  are  given  do  not  show  that  the 
growth  was  formed  of  columnar  cells.  The  extreme  care 
with  which  the  author  investigated  the  case  appears  to  imply- 
that  it  was  considered  one  of  exceptional  rarity,  and  not 
following  the  usual  type.  Three  other  cases  are  referred  to 
as  resembling  this  one,  two  reported  by  Lubarsch  and  one  by 
Langhaus. 

The  cases  are  too  few  to  admit  of  any  specialisation  as  re- 
gards relative  frequency  in  one  portion  of  the  canal  or  in 
another.  Such  cases  as  I  have  been  able  to  find  reported 
show  that  carcinoma  may  occur  at  any  part.  Thus  in  one 
case,  reported  by  Eiegel,^  the  disease  was  situated  in  the  upper 
part  of  the  jejunum  ;  in  another,  by  Morton,''*  it  was  at  the 
lower  end  of  the  ileum. 

Whether  the  disease  commence  as  a  nodule  beneath  the 
mucous  membrane,  or  as  a  plaque  on  the  surface,  its  progress 
is  usually  round  the  bowel,  so  that  sooner  or  later  a  circular 
constriction  results,  with  all  the  attendant  ills  of  gradual 
obstruction  to  the  onward  passage  of  fasces.  The  constriction 
may  be  so  tight  that  the  affected  portion  appears  as  if  en- 
circled by  a  piece  of  string.  In  addition  to  the  growth  inwards 
which  narrows  the  canal,  the  intestinal  coats  are  sometimes 
greatly  thickened  by  the  infiltrating  growth  of  the  tumour. 
A  certain  amount  of  ulceration  takes  place  on  the  surface  of 
the  growth  internally. 

When  once  constriction  has  become  a  marked  feature  in 
the  case,  other  changes  ensue  in  the  part  of  the  bowel  above. 
These  have  already  been  fully  referred  to  in  discussing 
cicatricial  stricture,  and  being  quite  similar  need  not  be  re- 
peated here. 

Secondary  deposits  are  occasionally  found  infiltrating  the 
intestinal  wall.  Eansom  ^  refers  to  a  case  recorded  by  Chiari, 
where  the  ileum  was  infected  with  a  secondary  growth,  the 
primary  disease  being  in  the  gall  bladder.     These  secondary 

'  Lancet,  1890,  vol.  ii.  p.  1020. 

-  Medical  Chronicle,  1891,  vol.  xiii.  p.  127. 

^  Trans.  Path.  Soc.  Lond.  1893,  vol.  xliv.  p.  89. 

■=  Lancet,  1890,  vol.  ii.  p.  1020. 


414  THE   JEJUNUM   AND   ILEUM 

tumours,  however,  are  not  prone  to  produce  any  obstructive 
symptoms. 

Symptoms. — There  is  httle,  if  anything,  which  can  be  said 
to  distinguish  the  symptoms  of  carcinomatous  stricture  from 
those  which  follow  upon  stricture  from  any  other  cause,  with 
the  one  possible  exception  that  in  some  instances  a  tumour 
may  be  felt  through  the  abdominal  parietes.  In  the  case 
reported  by  Morton,  where,  as  already  stated,  the  tumour 
existed  at  the  lower  end  of  the  ileum,  a  well-defined  lump 
aboat  the  size  of  a  walnut  could  at  times  be  felt  in  the  left 
iliac  fossa.  In  Eiegel's  case,  quoted  above,  the  situation  of 
the  stricture  high  up  in  the  jejanum  led  to  the  case  being 
taken  for  one  of  disease  at  the  pylorus.  The  stomach  became 
dilated,  and  there  was  constant  vomiting.  The  one  distin- 
guishing feature,  however,  was  the  frequent  presence  of  bile 
in  the  vomit,  which  showed  that  the  obstruction  was  below 
the  duodenal  orifice  of  the  common  bile  duct. 

A  case  is  reported  by  Voelcker  ^  which  is  called  malignant 
disease,  but  is  not  classed  as  either  carcinoma  or  sarcoma. 
The  upper  part  of  the  jejunum  was  the  seat  of  a  soft  ulcerating 
new  growth.  The  gut  at  the  seat  of  the  disease  was  much 
dilated.  It  ulcerated  into  the  ascending  colon.  The  patient, 
a  man,  seemed  quite  well  up  to  within  three  weeks  of  his 
death,  when  he  was  seized  with  diarrhoea,  which  continued  till 
the  end. 

Treatment. —  The  treatment  of  stricture  from  carcinoma 
resembles  in  all  respects  stricture  due  to  other  causes  ;  either 
the  distended  bowel  above  should  be  opened  and  a  fgecal  fistula 
formed  to  afford  temporary  relief,  as  in  Morton's  case,  or  the 
more  radical  measure  of  enterectomy  should  be  performed. 

Sarcoma. — Sarcoma,  like  carcinoma  of  the  small  intestine, 
is  a  comparatively  rare  disease.  It  is  equally  fatal  in  cha- 
racter, but  possesses  differences  in  its  mode  of  involvement 
of  the  bowel,  and  in  the  symptoms  to  which  it  gives  rise. 

Sarcoma  affects  the  bowel  in  two  forms.  In  the  first  it 
resembles  the  fibromata,  adenomata,  and  myomata  in  growing 
in  the  shape  of  a  polypus  and  projecting  into  the  canal;  in 
the  second  it  extends  around  the  wall,  thickening  it  and  at 

'   Trans.  Path.  Soc.  Loncl.  1893,  vol.  xliv.  p.  88. 


SARCOMA  415 

the  same  time  widening  the  canal.  In  the  polypoid  form  it  is 
usually  of  the  spindle-celled  variety  of  sarcoma  ;  in  the  other 
it  is  the  round- celled. 

Primary  sarcoma  arises  generally  in  the  submucous  coat ; 
when  the  coats  are  invaded  from  disease  of  the  mesenteric 
glands,  it  should  be  considered  secondary  involvement,  not 
primary  disease  of  the  bowel. 

As  the  growth  proceeds  it  infiltrates  all  the  coats  with  the 
exception  of  the  serous,  which  is  but  rarely  involved.  The 
effect  of  the  infiltration  is  to  produce  great  thickening,  which 
in  some  instances  leads  to  increase  in  the  normal  calibre  of 
the  canal,  but  in  others  to  encroachment,  so  that  the  bowel 
becomes  almost  stenosed.  At  a  meeting  of  the  Glasgow 
Pathological  and  Clinical  Society,'  illustrations  of  both  these 
conditions  were  shown.  In  the  specimen  presented  by  W.  J. 
Fleming  and  J.  Lindsay  Steven,  the  tumour  was  situated  in 
the  first  part  of  the  jejunum,  and  the  bowel  was  dilated  in 
what  might  be  termed  the  body  of  the  tumour.  In  the  speci- 
men presented  by  Henry  Eutherfurd,  the  tumour  was  situated 
in  the  lower  part  of  the  ileum,  and  the  canal  was  so  encroached 
upon  by  the  growth  that  nothing  larger  than  a  No.  8  bougie 
could  be  passed.  The  effect  of  the  extensive  infiltration  of  the 
gut  wall  is  to  convert  the  bowel  into  a  solid  tube.  In  cases 
where  the  tumour  mass  is  very  large,  and  involves  also  the 
mesentery,  the  origin  of  the  tumour  may  be  open  to  some 
doubt,  as  there  is  as  much  probability  that  it  may  have 
arisen  in  the  mesenteric  glands  as  in  the  submucous  tissue  of 
the  bowel. 

Sarcoma  is  most  frequently  met  with  during  the  third  and 
fourth  decades  of  life.  Out  of  fourteen  cases  collected  by 
Madelung  ^  the  youngest  patient  was  4  years  and  the  oldest 
52. 

Symptoms. — It  often  happens  that  general  or  constitutional 
symptoms  manifest  themselves  for  some  time  prior  to  the 
appearance  of  local  evidences  of  disease.  Thus  there  is  pro- 
gressive emaciation,  loss  of  appetite,  and  loss  of  strength. 
The  patient  has  a  sallow  complexion  and  is  cachectic.  Local 
symptoms  show  themselves  by  gastric  troubles,  with  ill- defined 

'   Trans.  1893,  vol.  iv.  p.  206. 

■•^  Ccntralh'.att  fur  CMrurgic,  1892,  No.  30,  p.  G17. 


416  THE   JEJUNUM   AND   ILEUM 

pain  in  the  abdomen.  The  bowels  become  irregular,  at  one 
time  constipated,  at  another  loose,  or,  as  in  Fleming's  case, 
they  remain  quite  regular.  In  cases  where  the  tumour  gives 
rise  to  constriction  and  narrowing  of  the  canal  there  may 
be  repeated  attacks  of  obstruction,  gradually  increasing  in 
severity,  as  occurred  in  Eutherfurd's  case.  In  most  instances 
palpation  of  the  abdomen  will  reveal  the  presence  of  a  tumour. 
It  would  seem  that  in  some  cases  the  tumour,  for  some  unac- 
countable reason,  may  disappear  for  a  time.  In  Fleming's 
case  this  was  observed,  and  in  a  case  recorded  by  Baltzer  '  the 
patient  stated  that  for  a  time  the  hardness  which  he  had 
previously  felt  had  disappeared.  It  is  possible  that  such  dis- 
appearance is  only  delusis^e  :  that  the  bowel  has  altered  its 
position  or  been  overlapped  by  other  coils  distended  with  gas. 

The  course  of  the  disease  is  usually  rapid.  In  most  cases 
death  follows  in  about  nine  months  from  the  commencement 
of  the  symptoms. 

As  already  indicated,  the  small  intestine  may  be  secondarily 
involved.  Probably  this  involvement  is  most  frequent  when 
the  disease  has  its  origin  in  the  mesenteric  glands.  It  is, 
however,  met  with  when  the  disease  has  its  primary  origin 
in  more  distant  parts.  Perry  ^  records  the  infection  of  the 
ileum  in  three  separate  parts  by  discoid  growths  which  pro- 
jected about  a  quarter  of  an  inch  above  the  mucous  membrane. 
The  primary  tumour  was  situated  in  the  right  tonsil. 

Treatment. — Eemoval  of  the  affected  part  can  alone  be  of 
any  service.  This,  however,  can  only  be  effected  in  the  early 
stage  of  the  disease,  when  the  tumour  has  not  by  direct  exten- 
sion become  adherent  to  and  infiltrated  other  parts.  Baltzer,^ 
out  of  thirteen  cases  which  he  collected,  reports  upon  four 
which  were  operated  upon  by  excision.  Two  died  within 
twenty-four  hours  of  the  operation,  and  two  recovered. 

For  any  further  details  of  this  disease  the  reader  should 
consult  the  two  papers  of  Madelung  and  Baltzer,  which  contain 
all  the  most  recent  references  to  the  subject. 

Lymphoma,  Lympliadenoma. — This  kind  of  tumour  practi- 
cally belongs  to  the  class  of  sarcomata,  and  probably  in  many 

'  Archiv  fiir  klin.  Chir.  1892,  vol.  xliv.  p.  729. 
^  Trans.  Path.  Soc.  Lond.  1893,  vol.  xliv.  p.  89. 
^  Archiv  fiir  klin.  Chir.  1892,  vol.  xliv.  p.  749. 


OBSTRUCTION    FROM   PRESSURE  417 

instances  is  described  as  such.  In  structure  it  consists  of 
very  small  round  cells  contained  in  the  meshes  of  a  delicate 
network  of  fibrils. 

When  arising  in  the  bowel  wall,  the  tumour  causes  changes 
indistinguishable  from  those  just  described  in  the  case  of 
sarcoma.  The  lumen  of  the  canal  may  be  increased.  The 
tumour  may  form  a  considerable  mass,  and  does  not  tend  to 
degenerate. 

Taylor  '  recorded  a  case  of  a  tumour  which  involved  nine 
inches  of  the  jejunum,  the  lumen  of  which  was  increased  in 
diameter.  The  mass  measured  seven  by  six  inches  trans- 
versely, and  two  inches  in  thickness.  The  tumour  could  be 
felt  in  the  abdomen.  The  patient's  symptoms  were  slight ; 
he  suffered  occasionally  from  griping  pain,  with  frequent  but 
not  loose  motions. 


CHAPTEE   L 

8.    EXTEENAL    PRESSURE.       9.    PERITONITIS,    ENTERITIS.      10.    CON- 
GENITAL   ABNORMALITIES,    MALDEVELOPMENTS.      NEUROSES 

8.  Pressure  upon  the  small  and  large  intestine  from  without. 
Pressure  upon  the  bowel  in  order  to  produce  symptoms  must 
narrow  its  lumen,  and  the  diminution  so  effected  results  in 
obstruction.  Two  factors  of  primary  importance  in  the  pro- 
duction of  obstruction  by  external  pressure  are  immobility 
of  the  bowel  and  counter-resistance.  Hence  it  is  found  that 
the  upper  part  of  the  jejunum  and  the  duodenum,  the  cfecum, 
the  sigmoid  flexure,  and  the  rectum  below,  being  the  parts 
most  fixed  and  most  protected  around  by  resistant  bony  and 
cartilaginous  walls,  are  the  regions  of  the  intestinal  canal 
most  frequently  obstructed  from  external  pressure  by  tumours 
and  abscesses. 

Tumours  arising  within  the  pelvic  cavity  are  specially 
prone  to  produce  pressure  on  the  rectum.  Numerous  examples 
of  such  tumours  are  found  in  connection  with  the  uterus  and 
ovary.     Cropf '^  reports  a  case  of  acute  obstruction  produced 

'   Trans.  Path.  Soc.  Loud.  1877,  vol.  xxviii.  p.  135. 
-  Anmial  of  the  Universal  Medical  Sciences,  1893,  vol.  iii.  C — 55. 

E  E 


418  THE   INTESTINES 

by  pressure  of  an  ovarian  cystoma.  After  removal  of  the 
growth  all  symptoms  disappeared.  Ricard  ^  reports  a  case 
of  pressure  produced  by  a  dermoid  cyst  of  the  ovary.  At  a 
Branch  meeting  of  the  British  Medical  Association  in  Bir- 
mingham, Kauffmann  ^  showed  specimens  of  the  ovary  and 
uterus  taken  from  a  patient  who  died  of  rupture  of  the 
large  intestine  with  fsecal  extravasation.  There  was  cancer 
of  the  ovary  and  multiple  fibromata  of  the  uterus.  The 
entire  mass  had  blocked  the  sigmoid  flexure  and  produced 
complete  obstruction. 

In  some  instances  a  tumour,  when  of  a  malignant  nature, 
tends  not  only  to  obstruct  by  pressure,  but  invades  also  the 
walls  of  the  gut.  In  a  case  recorded  by  Meyer,^  the  tumour 
extended  from  the  abdominal  wall.  It  has  also  been  indicated 
how  sarcoma  arising  within  mesenterie  glands  is  liable  to 
extend  to  the  bowel,  press  upon  the  canal  and  invade  its 
coats. 

Solid  tumours  arising  from  any  organ  within  the  abdomen 
are  more  liable  to  produce  pressure  than  cysts  or  abscesses. 
Nevertheless  examples  of  the  latter  are  occasionally  met  with. 
Aly''  records  a  case  where  the  pressure  was  produced  by  an 
abscess  originating  in  a  peritoneal  gland;  and  Lucas- 
Championniere  ^  operated  upon  a  case  where  the  pressure 
resulted  from  a  mass  of  effused  blood  after  laparotomy :  the 
symptoms  appeared  on  the  eighth  day  after  the  operation. 

Greig  Smith  "^  records  an  interesting  case  of  pressure  by 
a  tumour,  at  first  thought  to  be  malignant,  but  which  subse- 
quently disappeared.  It  extended  upwards  from  the  pelvis 
towards  the  umbilicus  and  pressed  upon  the  ileum.  The 
symptoms  of  obstruction  were  not  very  acute  at  first,  but 
gradually  became  so ;  the  abdomen  was  much  distended, 
peristalsis  was  visible,  there  was  vomiting  and  intermittent 
pain  occurring  daily,  usually  in  the  afternoon  and  evening. 

Symptoms. — It  is  unusual  for  symptoms  of  obstruction  to 


'  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  iii.  C— 61. 
2  Brit.  Med.  Journ.  1895,  vol.  i.  p.  702. 

*  Annals  of  Surgery,  1895,  vol.  xxi.  p.  73. 

*  Annual  of  the  Universal  Medical  Sciences,  1888,  vol.  i.  p.  357. 

*  Revue  de  CJdrurgie,  1892,  p.  264. 
'  Lancet,  1891,  vol.  i.  p.  646. 


OBSTRUCTION   FROM   PERITONITIS  419 

arise  from  external  pressure  without  its  being  known  that  a 
swelHng  or  tumour  hahle  to  produce  such  obstruction  exists. 
In  other  words,  before  a  tumour  is  hkely  to  produce  pressure 
sufficiently  great  to  cause  obstruction,  it  will  have  rendered 
its  existence  perceptible  either  to  the  eye  or  to  the  hand. 
The  diagnosis  therefore  of  the  true  cause  is  frequently  not 
difficult.  Although  the  obstruction  may  be  complete,  the 
symptoms  are  not  ushered  in  with  the  same  degree  of  acute- 
ness  as  is  the  case  in  many  other  forms  of  obstruction  ;  nor 
throughout  their  course  are  they  so  urgent.  Pain  is  chiefly 
paroxysmal  and  not  severe.  Vomiting  is  not  incessant. 
There  is  abdominal  distension  with  visible  peristalsis.  The 
intermittency  of  the  symptoms,  especially  at  the  outset,  is 
due  to  the  fact  that  the  increased  vis  a  tergo  occasionally 
overcomes  somewhat  the  external  pressure,  so  that  some 
temporary  relief  is  obtained.  The  more  persistent  and  urgent 
the  symptoms,  the  more  complete  must  be  considered  the 
obstruction. 

Treatment. — Eemoval  of  the  cause  of  pressure  will  in 
most  instances  be  followed  by  relief  of  the  symptoms.  When, 
however,  the  gut  has  been  invaded  or  become  inseparably 
adherent,  it  will  be  necessary  to  remove  the  part  concerned  at 
the  same  time.  Meyer  succeeded  in  his  case  in  effecting  ana- 
stomosis by  Murphy's  button,  after  removing  the  tumour  and 
adherent  gut  in  one  piece. 

9.  Peritonitis  and  enteritis. — Inflammation  affecting  the 
bowel  itself  or  derived  from  without,  as  in  the  case  of  peri- 
tonitis, leads  to  obstruction.  As  Wilts  tersely  expresses  it, 
*  an  inflamed  bowel  is  a  paralysed  bowel,'  and  a  paralysed 
segment  of  bowel  acts  as  an  effectual  barrier  to  the  onward 
progress  of  its  contents. 

When  obstruction  arises  from  peritonitis,  the  cause  itself 
is  sufficiently  grave  to  mask  the  prominence  of  symptoms 
which  owe  their  origin  directly  to  the  obstruction.  It  would 
be  better  to  say  that  the  symptoms  of  obstruction  are  those 
of  peritonitis  ;  and  for  that  reason  it  frequently  becomes 
a  matter  of  great  difficulty  in  diagnosis  to  determine  in 
certain  cases  whether  we  are  dealing  with  peritonitis  as  a 
primary  disease  or  with  obstruction  from  some  mechanical 
cause. 


420  THE   JEJUNUJM   AND   ILEUM 

The  symptoms  of  uncomplicated  peritonitis  need  not  be 
entered  upon  at  any  great  length  here  ;  in  most  respects  they 
resemble  those  which  have  already  been  frequently  alluded  to 
as  occurring  in  peritonitis  the  result  of  injuries  and  diseases 
of  the  intestines.  Most  prominently  stands  out  the  pain 
which  is  felt,  frequently  first  at  the  lower  part,  although  no 
region  is  exempt  from  it  at  the  outset.  It  may  be  of  a 
pinching,  aching,  burning,  or  cutting  character,  and  is  in- 
creased by  pressure  or  by  movement.  The  patient's  attitude 
with  regard  to  the  pain  is  somewhat  characteristic.  If 
moving  about  or  sitting,  he  stoops ;  if  in  bed  he  lies  on  his 
back  with  his  head  and  shoulders  raised  and  his  knees  and 
thighs  flexed.  Every  effort  is  made  to  relax  the  abdominal 
parietes  and  protect  the  parts  from  pressure.  The  abdominal 
muscles  become  fixed,  and  any  attempt  to  palpate  the  part 
increases  the  rigidity.  There  is  usually  some  fever,  with  all 
the  various  concomitants  which  generally  attend  rise  of 
temperature.     Vomiting  is  frequently  present. 

Peritonitis,  as  frequently  pointed  out,  is  extremely  variable 
in  its  sj-mptoms.  The  exact  converse  of  one  case  may  be 
found  in  another.  Temperature,  in  place  of  being  high,  may 
be  low  :  instead  of  a  hot  flushed  face,  pallor  with  cold  perspi- 
ration :  in  place  of  a  rigid  abdomen,  a  lax  one  with  little  or 
no  pain  ;  while  the  bowels  instead  of  being  confined  are  loose, 
with  an  approach  in  some  cases  to  diarrhoea. 

Enteritis,  which  in  some  respects  much  resembles  peri- 
touitis,  does  not  as  a  rule  come  under  the  observation  of 
the  surgeon  in  its  early  stages  ;  and  as  it  has  already  been 
referred  to,  no  further  mention  of  it  need  be  made  here. 
(See  page  301.) 

10.  Congenital  abnormalities,  maldevelopments. — By  far  the 
largest  number  of  malformations  of  the  small  intestine  are 
connected  in  some  way  with  the  vitelline  duct.  Either  this 
has  remained  patent,  or  its  too  complete  obliteration  has 
resulted  in  stricture.  Between  these  two  extremes  there  is 
every  grade  of  maldevelopment. 

Hudson  ^  has  adopted  the  following  useful  classification 
of  malformations  based  on  variations  found  in  the  develop- 

'   Trmis.  Path.  Soc.  Loncl.  1889,  vol.  xl.  p.  98. 


CONGENITAL   ABNORMALITIES  421 

meiit  of  the  vitelline  duct.     The  cases  are  divided  into  two 
groups. 

In  the  first  group  are — 

(1)  Cases  in  which  the  ileum  opens  freely  at  the  umbilicus, 
and  the  chief  part  of  the  evacuations  of  the  bowel  is  discharged 
by  this  fistula. 

(2)  Cases  with  a  small  fistulous  opening  at  the  umbilicus, 
admitting  a  probe  and  occasionally  allowing  the  passage  of 
faeces  and  flatus. 

(3)  A  tubular  ^prolongation  of  the  ileum,  connected  with  the 
umbilicus,  either  directly  or  by  a  longer  or  shorter  fibrous  cord. 

(4)  A  fibrous  cord  connecting  otherwise  normal  intestine 
or  mesentery  with  the  umbilicus. 

(5)  Meckel's  diverticulum,  of  variable  length  and  shape, 
either  terminating  in  a  rounded  extremity  or  hammer- shaped 
dilatation. 

(6)  Slight  saccular  pouching  of  the  intestine  in  this  region. 
In  the  second  group  are  included  instances  of  excessive 

obliteration  of  the  duct  where  the  lumen  of  the  bowel  has 
become  involved,  arranged  as  follows  : 

(1)  Slight  constriction  of  the  gut,  with  more  or  less 
obvious  diminution  of  its  calibre,  and  but  few  changes  above 
or  below. 

(2)  Marked  stricture,  causing  secondary  changes  due  to 
dilatation  of  the  gut  above,  and  producing  signs  of  obstruc- 
tion. 

(3)  Complete  occlusion  of  the  gut  by  a  septum  formed  of 
mucous  membrane,  the  muscular  and  serous  coats  remaining 
continuous. 

(4)  Complete  solution  of  continuity  of  the  ileum. 

In  addition  to  the  malformations  connected  with  this  par- 
ticular part  of  the  ileum,  other  congenital  defects  are  met  with 
in  the  jejunum.  Turner  ^  showed,  at  the  Pathological  Society 
of  London,  a  specimen  of  occlusion  of  about  an  inch  of  the 
middle  part  of  the  jejunum.  It  was  shut  off  from  the  parts 
above  and  below  by  membranous  diaphragms.  The  occluded 
portion  contained  a  small  quantity  of  mucous  secretion  which 
could  not  be  pushed  past  either  boundary.  The  specimen 
was  obtained  from  the  body  of  a  small  wasted  infant  aged 

'   Trans.  1R«7,  vol.  xxxviii.  p.  145. 


422  THE   JEJUNUM   AND   ILEUM 

4  days.  Another  case  is  reported  by  Thomas,'  where  lapa- 
rotomy was  performed  for  complete  obstruction   in  an  infant 

5  days  old.  At  the  post  mortem  the  jejunum  was  found  to 
end  in  a  blind  extremity  about  thirtj^-two  inches  from  the 
pylorus.  A  somewhat  similar  instance  is  reported  by 
Thomson.^  The  child  lived  for  ten  days ;  and  at  the  post 
mortem,  the  jejunum,  a  few  inches  from  the  duodenum,  was 
found  to  end  in  an  abrupt  rounded  extremity,  a  gap  existing 
between  it  and  the  next  portion  of  the  bowel.  Willet  ^  records 
two  instances,  one  where  the  occlusion  was  at  the  junction 
of  the  duodenum  and  the  jejunum,  and  the  other  about  the 
junction  of  the  jejunum  and  the  ileum. 

In  illustration  of  Hudson's  second  group  of  cases  are  three 
of  imperforate  ileum  recorded  by  Sutton.* 

The  subject  of  congenital  stricture  has  already  been  alluded 
to,  and  Eolleston's  case  (see  page  397)  may  be  referred  to 
again  here,  as  probably  illustrating  maldevelopment  of  the 
valvule  conniventes  of  the  jejunum. 

A  rare  malformation  is  described  and  depicted  by  Buzzi,'"^ 
of  a  diverticulum  of  the  jejunum.  It  was  found  in  the  body 
of  a  man  aged  77  years,  and  was  situated  about  three  feet 
from  the  duodenum. 

Of  anatomical  rather  than  pathological  interest  is  the 
transposition  of  the  intestines.  Dexter  ^  records  a  specimen, 
found  in  the  dissecting  room,  of  the  sigmoid  having  a  long 
mesentery  and  lying  in  the  right  iliac  fossa,  while  the  coils 
of  the  small  intestine  were  alone  found  in  the  left  iliac  fossa. 
(Sse  also  Malformations  of  Large  Intestine.) 

Symptoms. — Many  of  these  congenital  defects  are  purely  of 
pathological  interest,  and  are  found  more  among  the  records 
of  the  pathologist  than  of  the  clinician.  On  the  other  hand, 
cases  are  sufficiently  numerous  to  show  that  not  infrequently 
they  are  a  source  of  grave  trouble. 

Nothing  further  need  be  said  here  regarding  the  mode  i 

*  Brit.  Med.  Journ.  1886,  vol.  ii.  p.  925. 

^  Edinburgh  Med.  Journ.  1892,  vol.  xxxvii.  p.  840. 
s  Trans.  Path.  Soc.  Lond.  1894,  vol.  xlv.  p.  80. 

^  International  Journal  of  the  Medical  Sciences,  1889,  N.S.  vol.  xcviii. 
p.  457. 

*  Vircliow's  Archiv,  1885,  vol.  c.  p.  357. 

*  Boston  Med.  and  Surg.  Journ.  1893,  vol.  xxix.  p.  479. 


CONGENITAL   AJJNOliMALlTlES  423 

which  a  diverticukim  or  its  ligamentous  remnant  is  capable  of 
strangulating  a  loop  of  bowel ;  nor  is  it  necessary  to  repeat 
what  has  already  been  stated  regarding  the  symptoms  con- 
nected with  congenital  stricture. 

Complete  occlusion  of  the  bowel,  such  for  instance  as 
exists  in  cases  where  the  proximal  extremity  ends  in  a  cul- 
de-sac,  gives  rise  to  symptoms  shortly  after  the  birth  of  the 
child. 

At  first  the  child  may  readily  take  the  breast,  but  vomit- 
ing soon  sets  in,  and  it  is  found  that  everything  taken 
is  rapidly  returned.  Nothing  is  passed  by  the  bowel  except 
a  little  mucus.  In  Thomson's  case  where  the  jejunum  ter- 
minated in  a  blind  extremity  a  little  below  the  duodenum, 
some  half-teaspoonful  of  dark  green  matter,  homogeneous 
and  slimy,  was  passed.  As  a  rule,  however,  it  is  not 
easy  to  mistake  the  comparatively  small  quantity  of  slimy 
material  ejected,  with  the  normal  meconium  which  should 
be  excreted. 

Distension  of  the  abdomen  is  not  seen  at  first,  but  in  the 
course  of  a  day  or  two  it  appears  and  forms  a  marked 
feature  in  the  emaciated  condition  of  other  parts  of  the 
body. 

It  is  never  possible  to  predict  with  any  degree  of  certainty 
in  what  region  of  the  bowel  the  occlusion  exists,  whether  in 
the  duodenum,  the  jejunum,  or  the  ileum. 

The  number  of  days  which  an  infant  with  complete 
obstruction  is  likely  to  live  varies,  and  depends  probably  more 
upon  the  natural  vigour  and  vitality  of  the  child  than  upon 
the  situation  of  the  obstruction.  In  Thomson's  case  where 
the  obstruction  was  high  up,  death  resulted  on  the  tenth  day ; 
while  in  one  of  Hudson's  cases,  where  the  occlusion  was  low 
down—  sixteen  inches  above  the  caecum — death  occurred  on 
the  third  day.  The  opposite  might  naturally  have  been  ex- 
pected if  life  depended  upon  the  distance  of  the  obstruction 
from  the  stomach. 

Treatment. — The  only  possible  measure  in  the  treatment  of 
obstruction  from  occlusion  is  laparotomy  and  the  formation 
of  an  artificial  anus.  Tliis  has  been  attempted  several  times  ; 
and  if  it  has  not  been  the  means  of  hastening  death,  it  has 
not  yet  apparently  been  successful  in  prolonging  life. 


424  THE   JEJUNUM   AND   ILEUM 

The  only  other  congenital  defect  which  comes  under  the 
surgeon's  observation  and  treatment  is  that  associated  with 
incomplete  closure  of  the  vitelline  duct.  As  already  pointed 
out,  this  condition  may  exist  in  the  extreme  form  of  an 
abnormal  anus  at  the  umbilicus,  where  practically  all  the 
faeces  are  discharged  ;  or  merely  as  a  fistula  through  which  a 
small  quantity  of  mucus  or  faecal  matter  exudes. 

The  former,  the  much  graver  of  the  two  conditions,  will 
probably  need  some  plastic  operation  for  its  cure.  There  are 
two  advantages,  however,  in  delaying  any  operative  inter- 
ference. The  first  is,  that  young  infants  do  not  bear  opera- 
tions well,  and  the  second,  that  there  is  the  possibility  of  the 
aperture  closing.  If  the  umbilical  orifice  has  shown  distinct 
evidence  of  contraction,  it  may  prove  possible  to  complete  the 
occlusion  by  the  application  of  the  actual  cautery  to  its  edges. 
This  measure  is,  however,  rarely  successful,  and  a  plastic 
operation  of  the  nature  of  transplantation  of  a  skin  flap  may 
be  required. 

In  cases  of  the  second  and  less  severe  kind  of  faecal  fistula, 
it  frequently  happens  that  evidences  of  a  fistula  are  not 
manifest  until  a  few  days  after  birth  ;  that  is  to  say,  until  the 
time  of  usual  separation  of  the  cord,  about  the  fifth  or  sixth 
day.  The  orifice  of  the  fistula  is  then  sometimes  marked  by 
a  little  red  vascular  papilla  or  polypus,  at  the  base  of  which  a 
small  opening  exists,  which  admits  of  the  insertion  of  a  probe 
for  a  variable  distance.  In  not  a  few  instances  these  fistulae 
close  in  the  course  of  a  few  days.  Should  they  remain 
patent  the  canal  may  be  cauterised,  or,  if  necessary,  a  plastic 
operation  performed. 

Intestinal  neuroses. — There  occasionally  come  under  the 
observation  of  the  surgeon  cases  of  intestinal  disturbance 
which  appear  to  have  their  origin  either  in  some  purely  mental 
aberration  or  in  some  local  nerve  irregularity.  Among  the 
former  are  cases  of  supposed  ingestion  of  a  foreign  body,  when 
the  patient  imagines  he  feels  the  body  within  the  abdomen. 
In  some  instances  a  live  animal,  such  as  a  snake  moving 
about,  is  complained  of.  The  symptoms  are  sometimes  very 
distressing.  The  patient  complains  of  acute  discomfort  and 
pain,  vomits,  and  refuses  food. 

In  instances  of  local  nerve  disturbance  a  particular   seg- 


THE   LARGE    INTESTINE  425 

ment  of  bowel,  most  frequently  the  sigmoid  flexure,  undergoes 
irregular  contraction,  causing  vague  and  unpleasant  sensations 
in  the  patient,  and  sometimes  producing  tangible  evidence  of 
an  evanescent  tumour  in  the  affected  region. 

The  symptoms  in  these  two  classes  of  cases  are  probably 
explained  by  supposing  that  the  usually  imperceptible  peri- 
stalsis of  the  bowel  becomes  consciously  observed  and  felt  by 
the  patient,  who  in  many  instances  is  of  a  highly  neurotic 
temperament. 

When  these  cases  are  not  influenced  by  medical  treatment, 
laparotomy  should  be  resorted  to.  Nothing  will  be  found,  but 
in  some  mysterious  way  the  exploratory  operation  has  a 
beneficial  effect ;  so  much  so,  that  all  symptoms  suddenly  and 
entirely  disappear.  Treves  ^  has  recorded  some  interesting 
illustrations  of  cures  after  abdominal  exploration  in  this 
obscure  class  of  cases. 


SECTION  III 

THE   LAEGE   INTESTINE   AND   APPENDIX   YEEMIFOEMIS 

CHAPTEE   LI 

ANATOMY   AND    PHYSIOLOGY 

The  large  intestine  extends  from  the  termination  of  the  ileum 
in  the  right  iliac  region  to  the  anus.  It  measures  from  five 
to  six  feet  in  length,  and  constitutes  therefore  about  one-fifth 
of  the  entire  length  of  the  intestinal  canal.  For  descriptive 
purposes  it  is  divided  into  six  separate  regions,  known  re- 
spectively as  the  caecum,  ascending  colon,  transverse  colon, 
descending  colon,  sigmoid  flexure,  and  rectum. 

The  ccBcum.—  Th\Q  is  a  large  blind  pouch  constituting  the 
commencement  of  the  colon.  It  is  generally  considered  as 
that  portion  of  the  latter  which  is  situated  below  the  level  of 
the  ileo-cfecal  valve  (see  fig.  56).  It  lies  in  the  right  iliac 
fosea,  and  measures,  in  the  adult,  about  two  and  a  half  inchea 

'  Brit.  Med.  Journ.  1896,  vol.  i.  p.  2. 


426  THE   LARGE   INTESTINE 

both  in  its  vertical  and  transverse  diameters.  Posteriorly  it 
rests  usually  upon  the  psoas  muscle,  but  if  located  more  ex- 
ternally it  lies  in  contact  with  the  iliacus,  or  if  more  internally, 
on  the  brim  of  the  pelvis,  or  even  within  the  pelvic  cavity. 
Separating  the  muscle  from  the  bowel  is  the  iliac  fascia  with 
some  fatty  and  areolar  tissue.  In  front  are  some  coils  of  the 
small  intestine,  but  when  distended  it  touches  the  abdominal 
wall.  The  caecum  is  entirely  surrounded  by  peritoneum, 
which  admits  therefore  of  a  considerable  amount  of  movement 
of  the  part.  Attached  to  its  lower  and  hinder  part  is  the 
vermiform  appendix.  (For  a  full  description  of  this  appendage 
see  later.) 

The  ascending  colon. —  Commencing  at  the  caecum  opposite 
the  ileo-csecal  valve,  the  ascending  colon  extends  upwards  to 
the  under  surface  of  the  liver,  on  the  right  of  the  gall  bladder. 
It  lies  in  the  right  lumbar  and  hypochondriac  regions,  resting 
posteriorly  upon  the  quadratus  lumborum  below  and  the 
kidney  and  descending  part  of  the  duodenum  above.  In  front 
it  has  the  abdominal  parietes  with  some  coils  of  small  in- 
testine, which  also  lie  on  its  inner  side.  It  is  surrounded  by 
peritoneum  to  a  somewhat  variable  extent.  It  is  frequently 
completely  invested,  and  in  some  instances  to  the  extent  of 
possessing  a  meso-colon.  According  to  Treves,  in  26  per  cent. 
of  cases  in  which  right  lumbar  colotomy  is  performed  a  meso- 
colon may  be  expected. 

The  trmisverse  colon. — In  the  continuation  of  the  ascend- 
ing into  the  transverse  colon  a  bend  is  formed  beneath  the 
liver,  known  as  the  hepatic  flexure.  From  this  point  the  colon 
passes  across  the  abdomen  from  the  right  to  the  left  hypo- 
chondriac region.  Its  central  portion  lies  on  a  somewhat 
lower  and  anterior  level,  and  occupies  a  position  equally  in 
the  epigastric  and  umbilical  regions.  By  its  upper  surface  it 
is  in  contact  with  the  liver  and  the  gall  bladder,  the  stomach 
and  the  spleen.  Below  it  are  coils  of  the  small  bowel.  In 
front  it  has  the  great  omentum  and  the  abdominal  parietes, 
while  behind  it  is  the  third  portion  of  the  duodenum  and  the 
meso-colon.  It  is  ]3ractically  surrounded  by  peritoneum,  and 
by  its  meso-colon  is  rendered  the  most  movable  segment  of 
the  large  bowel. 

The  descending  colon. — As  on  the  opposite  side,  the  transverse 


ANATOMY  427 

colon  connects  with  the  descendmg  colon  by  a  sharp  bend. 
This  is  situated  just  below  the  spleen,  and  is  termed  the  splenic 
flexure.  From  this  point  the  bowel  takes  a  course  vertically 
downwards  from  the  left  hypochondriac  region,  through  the  left 
lumbar  to  the  left  iliac  region.  Posteriorly  it  is  connected 
with  the  left  crus  of  the  diaphragm,  the  left  kidney,  and  the 
quadratus  lumborum.  In  front  it  is  covered  by  coils  of  the 
small  intestine.  According  to  Treves,  this  part  of  the  bowel 
is  more  frequently  surrounded  by  peritoneum  than  the  corre- 
sponding ascending  portion  ;  that  is  to  say,  a  meso-colon  may 
be  expected  in  about  36  i)er  cent,  of  cases. 

The  sigmoid  flexure. — This  segment  of  the  large  bowel 
occupies  the  left  iliac  fossa,  and  extends  from  the  crest  of  the 
ilium  to  the  sacro-iliac  articulation,  where  it  terminates  in  the 
rectum.  It  derives  its  name  from  its  somewhat  peculiar  looped 
disposition.  It  is  concealed  by  small  intestine,  but  when  dis- 
tended comes  into  contact  with  the  abdominal  parietes.  It  is 
surrounded  by  peritoneum,  which  forms  a  meso-colon  and 
serves  to  retain  it  in  position. 

The  rectum,  the  remaining  portion  of  the  large  intestine, 
will  be  dealt  with  separately.     (See  Part  IV.) 

Structure. — The  large  intestine,  like  the  small,  has  four 
coats — serous,  muscular,  cellular  or  submucous,  and  mucous. 

The  serous  coat  consists  of  the  peritoneum  and  surrounds 
the  various  segments  of  the  bowel  to  the  extent  already 
described.  At  certain  parts,  more  particularly  in  the  transverse 
colon,  the  serous  coat  is  thrown  into  a  number  of  small  pouches 
filled  with  fat,  called  ajjpendices  ejnploicce. 

The  inuscidar  coat  consists  of  two  layers,  an  external  longi- 
tudinal and  an  internal  circular.  The  former,  while  it  distributes 
its  fibres  around  the  whole  circumference,  is  best  marked  in 
the  form  of  three  longitudinal  flat  bands  about  a  quarter  to 
half  an  inch  in  width.  One,  the  posterior,  is  situated  along 
the  attached  border  of  the  bowel;  a  second  is  disposed  anteriorly 
and  corresponds  along  the  arch  of  the  colon  to  the  attachment 
of  the  great  omentum,  but  lies  in  front  in  the  ascending  and 
descending  colon  and  the  sigmoid  flexure ;  the  third  is  placed 
laterally,  and  lies  on  the  inner  side  of  the  ascending  and 
descending  colon  and  on  the  under  border  of  the  transverse 
colon.     The  shortness  of  these  bands,  as  compared  with  the 


428  THE   LARGE   INTESTINE 

other  structures,  serves  to  throw  the  canal  into  a  sacculated 
condition,  so  that  when  divided  the  bowel  straightens  out  into 
a  uniform  channel. 

The  internal  circular  muscle  forms  a  comparatively  thin 
layer,  more  or  less  uniformly  distributed,  but  thickest  and 
best  marked  over  the  sacculated  portions  between  the  longitu- 
dinal bands. 

The  cellular,  areolar,  or  submucous  coat  resembles  the  same 
coat  in  the  small  intestine,  and  serves  to  connect  together  the 
mucous  and  muscular  tunics. 

The  mucous  menihrane  is  of  a  greyish  or  pale  yellow  colour, 
smooth  and  not  thrown  into  special  folds.  In  its  minuter 
structure  the  mucous  membrane  consists  of  a  muscular  layer, 
the  muscularis  mucosae,  of  a  quantity  of  retiform  tissue  in 
which  the  vessels  ramify,  and  of  a  basement  membrane  which 
supports  epithelium  of  the  columnar  shaped  variety. 

Situated  in  both  the  mucous  and  the  submucous  coats  are 
two  other  structures— the  simple  follicles  and  the  solitary  glands. 
Both  resemble  the  same  structures  found  in  the  small  intestine. 
The  former,  however,  are  more  numerous  and  closer  together. 
The  latter,  while  scattered  irregularly  throughout  the  entire 
length  of  the  caecum  and  colon,  are  more  abundantly  dis- 
tributed in  the  former. 

Vascular  supply. — The  large  intestine  receives  its  blood 
supply  from  branches  of  the  superior  and  inferior  mesenteric 
arteries.  The  csecum,  ascending  colon,  and  transverse  colon 
receive  their  arterial  supply  from  the  ileo-colic,  colica- 
dextra,  and  colica-media  branches  of  the  superior  mesenteric  ; 
while  the  descending  colon  and  the  sigmoid  flexure  receive 
their  supply  from  the  colica-sinistra  and  sigmoid  branches 
of  the  inferior  mesenteric.  The  final  distribution  of  these 
vessels  to  the  bowel  coats  resembles  in  all  respects  the  course 
taken  by  the  arteries  in  the  small  intestine. 

The  venous  blood  is  returned  by  the  superior  and  inferior 
mesenteric  veins,  which  correspond  in  their  distribution  to 
the  same-named  arteries.  The  inferior  opens  into  the  splenic 
vein,  while  the  superior  unites  with  the  same  vein  to  form 
the  vena  portse.  The  lymphatics,  after  leaving  the  bowel, 
pass  into  a  chain  of  glands  situated  close  to  the  intestinal 
wall,  and  are  continued  from  there  to  other  glands  situated 


ANATOMY  429 

along  the  vascular  arches  formed  by  the  arteries  previous  to 
their  distribution.  The  lymphatics  of  the  ctecum,  ascending 
and  transverse  colon,  after  passing  through  their  proper  glands, 
enter  the  mesenteric  glands ;  while  those  of  the  descending 
colon  and  sigmoid  flexure  pass  into  the  lumbar  glands. 

The  Nerve  supply  is  derived  from  the  sympathetic.     The 
superior  mesenteric  plexus,  which  is  a  derivative  of  the  great 


Fig.  56. — Ileo-c^cal  Valve,     (E.I.M.  Glasgow) 
The  colon  opened  to  show  the  normal  disposition  of  the  valve 

solar  plexus,  supplies  filaments  to  all  the  branches  of  the  artery 
of  the  same  name,  that  is  to  say,  it  supplies  the  caecum,  the 
ascending  and  transverse  colon  ;  while  the  remaining  portion 
of  the  large  intestine  is  supplied  by  radicles  from  the  inferior 
mesenteric,  itself  a  derivative  of  the  solar  plexus,  indirectly 
through  the  aortic  plexus. 

The  ileo-ccecal  valve. — At  the  junction  of  the  ileum  with 
the  csecum  are  two  reduplicated  folds  of  mucous  membrane, 


430  THE   LARGE    INTESTINE 

semilunar  in  shape  and  so  disposed  that  -when  their  margins 
are  in  apposition  any  regm^gitation  from  the  large  into  the  small 
intestine  is  prevented  (see  fig.  56).  At  the  base  of  the  macous 
valves  is  a  band  of  the  circular  muscle  fibres  continuous  with 
those  of  the  internal  coat  of  the  intestine.  The  inner  surface 
of  each  fold  is  smooth,  and  continuous  with  the  mucous 
membrane  of  the  ileum,  and,  like  it,  also  covered  with  villi : 
the  outer  surfaces,  on  the  other  hand,  are  continuous  with  the 
mucous  lining  of  the  caecum,  and,  like  it,  devoid  of  villi. 

Physiology. — The  functions  exercised  by  the  large  intestine 
are  much  the  same  as  those  of  the  small,  with  such  modifica- 
tions as  possibly  depend  upon  the  somewhat  altered  calibre 
of  the  canal  and  the  differences  in  the  structure  of  the 
mucous  membrane.  The  passage  of  the  contents  of  the 
small  intestine  into  the  large  is  followed  by  a  considerable 
retardation  in  their  progress.  A  further  change  is  effected 
in  the  consistency  of  the  faces  ;  from  a  somewhat  fluid  con- 
dition they  begin  to  assume  a  solid  form,  due  to  the  absorption 
of  the  more  liquid  portions.  Chemical  changes  take  place, 
whereby  the  intestinal  contents  become  acid  in  reaction  and 
develop  the  peculiar  characteristic  faecal  odour. 


CHAPTER   LII 

INJURIES.       INFLAMMATION.       ULCERATION 

Compared  with  those  of  the  small  bowel,  injuries  to  the  large 
intestine  are  much  less  frequently  met  with.  The  difference 
is  most  marked  in  the  cases  of  contusion  and  rupture ;  and 
the  reason  for  this  appears  to  be,  first,  the  anatomical  situa- 
tion of  the  bowel  around  the  abdominal  cavity,  and  second, 
the  fact  that  in  its  intimate  structure  it  is  strengthened  by 
longitudinal  muscle  bands. 

Poland '  has  recorded  5  cases  of  rupture  of  the  large  bowel 
out  of  a  series  of  64  fatal  cases  of  rupture  of  some  portion  of 
the  intestinal  canal ;  and  more  recently,  Curtis,^  in  a  report 

'  Guy's  Hospital  Reports,  1858,  3rd  series,  vol.  iv.  p.  164. 

^  International  Journal  of  the  Medical  Sciences,  1887,  vol.  xciv.  p.  329. 


INJURIES  431 

of  113  cases,  found  4  only  in  which  the  large  intestine  was 
involved. 

As  regards  the  causes  of  contusion  and  rupture,  their 
symptoms  and  treatment,  there  is  nothing  to  add  to  what  has 
already  heen  said  in  the  case  of  like  injuries  to  the  small 
intestine.  It  is  usually  not  until  operation  or  after  death  that 
the  exact  seat  of  the  lesion  is  ascertained. 

The  other  injuries,  such  as  punctured  and  incised  wounds, 
gunshot  wounds  and  lesions  arising  from  the  ingestion  or 
presence  of  foreign  bodies,  have  been  treated  of  in  conjunction 
with  the  like  wounds  to  the  small  intestines. 

Inflammation  of  the  caecum  — csecitis  or  typhlitis — occasion- 
ally results  from  the  lodgment  of  hard  fsecal  masses.  Such 
inflammation  may  extend  to  the  surrounding  tissues  and,  if 
coupled  with  ulceration  and  perforation,  give  rise  to  fsecal 
abscesses  in  the  iliac  and  inguinal  regions.  Typhlitis  in  its 
more  extended  sense  has  been  taken  to  include  affections  of 
the  appendix  vermiformis.  Inflammation,  however,  of  this 
latter  will  receive  separate  consideration  in  another  place. 

Inflammatioii. — Simple  inflammation,  or  colitis,  possesses 
little  or  no  interest  to  the  surgeon.  It  is  only  in  the  more 
advanced  stages  of  the  disease,  when  inflammation  has  led 
to  ulceration,  that  complications  not  infrequently  supervene 
in  which  the  question  of  operative  intervention  arises. 

Ulceration. — Considerable  difficulty  attaches  to  any  en- 
deavour to  classify  non-malignant  ulcers  of  the  large  bowel. 
Certain  forms,  such  as  the  typhoid  and  the  tubercular,  are 
sufficiently  distinctive ;  but  many  others,  in  addition  to  being 
etiologically  obscure,  possess  neither  a  pathological  nor  a 
clinical  basis  for  classification.  It  is  therefore  only  possible 
to  treat  the  subject  by  discussing  each  form  of  ulceration  under 
its  predominating  feature,  whether  this  be  clinical  or  patho- 
logical. 

Simjile  ulcer. — It  would  appear  that  in  not  a  few  instances 
ulceration  of  the  colon  takes  place  similar  in  all  respects  to 
that  which  is  met  with  in  the  stomach  and  the  duodenum  ;  that 
is  to  say,  the  simj)le  chronic  ulcer  of  these  regions  is  occasion- 
ally met  with  in  the  colon.  Like  these,  also,  the  ulcer  in  the 
colon  often  perforates,  and  produces  results  quite  similar. 
These  ulcers  may  be  found  in  any  part  of  the  large   bowel. 


432  THE    LARGE   INTESTINE 

Occasionally  only  one  large  ulcer  is  present ;  but  as  frequently, 
in  addition  to  this,  smaller  ones  exist  in  other  parts.  Like 
those  in  the  stomach,  no  definite  cause  is  known  to  account  for 
their  origin.  In  some  instances  the  patients  have  been  sub- 
jects of  Bright' s  disease ;  but  they  are  often  found  in  patients  who 
have  been  long  sufferers  from  other  forms  of  visceral  disease. 

Wilks  and  Moxon  ^  consider  it  probable  that  these  ulcers 
have  the  same  pathology  as  varicose  ulcers  of  the  leg,  that 
is  to  say,  they  are  due  to  some  retardation  of  the  venous  cir- 
culation. 

In  character  they  present  raised  indurated  edges,  some 
spreading,  while  others  may  be  healing.  They  extend  mostly 
in  a  transverse  direction  round  the  bowel,  so  that  it  is  possible 
they  may  in  some  instances  be  the  cause  of  simple  cicatricial 
stenosis. 

As  illustrations  of  this  form  of  ulceration  and  the  complica- 
tions to  which  it  may  give  rise,  the  following  cases  may  be 
quoted  : 

Parker  ^  records  two  cases  of  simple  ulcer  of  the  colon 
which  in  each  instance  led  to  the  formation  of  abscess.  In 
one,  the  case  of  a  woman  aged  18  years,  a  large  abscess,  which 
extended  over  the  right  ribs  from  the  liver  up  into  the  axilla, 
was  found  to  be  connected  with  an  ulcer  in  the  transverse 
colon.  In  the  other  case,  that  of  a  woman  aged  49  years,  a 
collection  of  faecal  matter  and  pus  extended  up  in  front  of  the 
liver  to  the  diaphragm.  It  was  connected  with  a  circular  ulcer 
in  the  caecum.  In  neither  of  these  cases  was  any  cause  for 
the  ulceration  discoverable.  In  a  case  reported  by  Oliver,^  the 
ulcer  perforated  and  caused  death  from  acute  general  peri- 
tonitis. The  ulcer  appeared  perfectly  clean,  it  measured  two 
inches  in  the  length  of  the  gut  and  one  inch  transversely.  It 
perforated,  but  the  contents  of  the  bowel  v^^ere  at  first  confined 
in  a  small  cavity  formed  by  the  anterior  surface  of  the  left 
broad  ligament,  the  left  border  of  the  uterus,  the  anterior  and 
left  walls  of  the  pelvis,  and  a  somewhat  long  sigmoid.  The 
abscess  subsequently  ruptured,  causing  the  peritonitis  of 
which   the   patient    died.     In   a   second   case  ^   reported    by 

'  Pathological  AnaLomij,  2iid  edit.  p.  409. 

2  St.  Bartholomew's  Hospital  Reports,  1887,  vol.  xxiii.  p.  213. 

'"  Lancet,  1891,  vol.  ii.  p.  122.  ••  Ihid.  1885,  vol.  i.  p.  424. 


ULCERATION  433 

the  same  surgeon,  two  ulcers  were  discovered  side  by  side, 
placed  longitudinally  in  the  large  intestine,  two  and  a  half 
inches  above  the  ileo-caecal  valve.  The  larger  measured  about 
half  an  inch  in  diameter,  the  other  would  admit  the  tip  of  a 
goose  quill.  Both  ulcers  had  perforated,  the  orifices  presenting 
round  and  regular  margins. 

Case  LXXXIX. — Sim2:)le  ulcer  of  sigmoid  flexure. 
A  man  aged  G8  years  had  for  some  months  been  in  a  debilitated  con- 
dition, with  no  other  symptoms  than  that  he  had  passed  blood  jjer  rectum. 
The  hfemorrhage  became  more  frequent,  and  blood  was  passed  several 
times  during  the  day.  An  inguinal  colotomy  was  performed,  when  it  was 
foimd  that  the  cause  of  the  haemorrhage  was  a  large  ulcer,  about  two  inches 
by  one  inch,  in  the  long  axis  of  the  bowel  and  over  the  free  side  of  the 
gut.  The  base  of  the  ulcer  appeared  to  be  peritoneum  only.  At  the  post 
mortem,  several  small  ulcers  with  punched-out  edges  were  found  on  the 
mucous  membrane  from  the  middle  of  the  rectum  to  the  middle  of  the 
transverse  colon.  There  were  contracted  granular  kidneys.  (Robinson, 
'  Trans.  Path.  Soc.  Lond.'  1891,  vol.  xlii.  p.  115.) 

Symptoms  and  Treatment. — The  cases  are  too  few  and  too 
obscure  in  their  symptoms  to  admit  of  being  diagnosed  during 
life.  The  presence  of  blood  in  the  motions,  with  the  absence 
of  any  other  obvious  bowel  symptoms  or  general  constitutional 
disturbance,  might  admit  of  the  supposition  of  simple  ulceration 
of  the  colon. 

The  failure  of  any  medicinal  or  conservative  measures  to 
check  the  htemorrhage,  and  the  increasing  debility  of  the 
patient,  would  reasonably  admit  of  some  operative  investi- 
gation ;  such  as,  for  instance,  was  attempted  in  Robinson's 
case.  Any  other  operative  measures  employed  in  dealing  with 
the  ulcer,  if  happily  found  and  exposed,  would  resemble  those 
suggested  and  practised  in  the  case  of  simple  chronic  ulcer 
of  the  stomach. 

Typhoid  ulcer. — Ulceration  of  the  colon  in  typhoid  fever, 
while  rare  as  compared  with  its  occurrence  in  the  small 
bowel,  is  occasionally  met  with,  and  cases  are  recorded  where 
perforation  has  taken  place.  Hadden '  records  one  such 
case,  where  a  round  perforation  an  eighth  of  an  inch  in 
diameter  existed  in  the  sigmoid  flexure.  The  entire  large 
intestine  was  ulcerated  to  an  extreme  degree  as  low  down  as 

'  Trans.  Path.  Soc.  Lond.  1887,  vol.  xxxviii.  p.  llo. 

F  F 


434  THE   LARGE   INTESTINE 

the  anus.  Another  case  of  perforation  is  recorded  by  Moore.' 
The  '  Transactions  '  of  the  London  Pathological  Society  contain 
the  records  of  many  cases,  showing  to  what  an  extent  the  large 
bowel  may  be  involved  in  ulceration.  Curnow  ^  showed  a 
specimen  where  the  large  bowel  was  more  ulcerated  than  the 
small.  Coupland^  also  exhibited  a  specimen  to  demonstrate 
extensive  implication  of  the  large  intestine. 

For  the  pathological  description  of  these  ulcers,  see  Small 
Intestine,  page  339. 

Tubercular  ulcer's. — The  large  intestine  is  liable  to  be 
extensively  involved  in  tubercular  ulceration.  This  region 
may  be  implicated  alone,  or  in  conjunction  with  the  small 
intestine.  In  a  case  recorded  by  Moore, ^  the  mucous  mem- 
brane showed  large  patches  of  ulceration  throughout  its  en- 
tire length ;  the  only  other  tubercular  disease  j)resent  was 
in  the  right  lung,  from  which  the  patient  died.  In  another 
case,  reported  by  Hale  White,'^  the  interior  of  the  caecum  was 
converted  into  an  enormous  tubercular  ulcer. 

These  ulcers  resemble  in  all  pathological  respects  those 
found  in  the  small  intestine,  and,  like  them,  are  liable  to  heal 
and  form  a  stricture,  or  progress  until  they  perforate. 

Symptoms  and  Treatment. — Tubercular  ulceration  of  the 
large  intestine  causes  symptoms  which  will  be  found  better 
discussed  in  works  on  medicine.  They  appear  to  be  variable. 
Sometimes  there  is  constipation,  but  there  may  be  intractable 
diarrhoea,  and  in  other  cases  there  is  entire  absence  of  any 
bowel  trouble. 

It  is  rarely  that  surgical  intervention  is  called  for  ;  never- 
theless, portions  of  the  large  intestine  have  been  successfully 
excised  for  tubercular  disease.  In  a  case  recorded  by  Korte,^ 
the  caecum  and  a  considerable  portion  of  the  colon  were  re- 
moved, the  patient  recovering. 

Sachs  ^  also  reports  a  successful  case  of  extirpation  in  a 
woman  aged  41  years ;  and  in  an  article  upon  the  subject 
refers  to  other  cases  by  Hofmokl,  Billroth,  Gussenbauer,  and 
Czerny. 

'   Trans.  Path.  Soc.  Lond.  1882,  vol.  xxxiii.  p.  150. 

2  Ihid.  1883,  vol.  xxxiv.  p.  116.  »  Ibid.  1884,  vol.  xxxv.  p.  209. 

*  Ihid.  1894,  vol.  xlv.  p.  81.  '  Ibid.  1885,  vol.  xxxvi.  p.  198. 

"  Annals  of  Surgery,  1895,  vol.  xxi.  p.  119. 

'  Archives  Gin^rales  de  MMecine,  1892,  vol.  ii.  p.  5G1. 


ULCERATION  435 

Dysenteric  ulcer. — Ulceration  the  result  of  dysentery  is 
most  frequently  met  with  in  the  rectum,  but  any  portion  of 
the  large  bowel  may  be  implicated.  It  is  usual  for  the  lower 
part  to  be  more  extensively  affected  than  the  upper. 

Considerable  variation  exists  in  the  size,  shape,  and 
arrangement  of  the  ulcers.  In  some  cases  they  are  circular 
and  distinct,  while  in  others  they  occur  in  irregular  groups. 
In  others,  again,  extensive  areas  are  involved,  so  that  small 
isolated  patches  of  mucous  membrane  are  seen  projecting  from 
the  surface. 

The  surgical  aspects  of  the  disease  exist  in  the  complica- 
tions which  may  arise  in  the  course  of  the  disease  or  subse- 
quently. Thus  perforation  may  take  place  or  peritonitis  arise 
from  extension  of  the  inflammation  to  the  peritoneum.  Severe 
hsemorrhage  occasionally  happens,  and  stricture  may  result 
from  the  healing  and  contraction  of  a  large  ulcerated  surface. 

General  idcerative  colitis. — Cases  occasionally  come  before 
the  physician  of  extensive  ulceration  of  the  colon,  a  disease 
which  appears  to  run  an  uninterrupted  fatal  course.  The 
mucous  membrane  of  the  bowel  is  in  some  places  completely 
destroyed,  while  in  others  islets  or  tags  are  left  which  have 
the  appeara.nce  of  small  polypi.  As  the  result  of  an  examina- 
tion of  twenty  cases  by  Tooth,  ^  the  following  are  some  of  the 
clinical  facts  brought  out. 

Females  are  more  frequently  attacked  than  males,  and  the 
average  age  at  which  the  disease  appears  is  about  31  years  in 
the  female  and  43  in  the  male.  There  are  apparently  no  pro- 
dromal symptoms,  nor  does  there  seem  to  be  any  predisposing 
cause  ;  in  nearly  all  the  cases  the  patients  appear  to  have  been 
in  good  health  at  the  time  of  onset.  The  disease  commences 
like  an  ordinary  attack  of  summer  diarrhoea.  The  patient 
passes  motions  several  times  a  day  ;  these  frequently  contain 
blood,  and  occasionally  sloughs.  The  stools  are  not  of  a 
dysenteric  character.  There  is  little  or  no  fever,  and  only 
occasionally  some  pain.  Eapid  emaciation  takes  place,  and 
death  ensues  usually  in  from  four  to  ten  weeks.  Perforation 
but  rarely  occurs.  At  the  post  mortem,  little  else  than  ulcera- 
tion of  the  large  intestine  is  met  with.  The  kidneys  in  some 
instances  have  shown  evidence  of  disease ;  and  it  is  maintained 

'  Trans.  Path.  Soc.  Lond.  1894,  vol.  xlv.  p.  66. 


436  THE   LARGE   INTESTINE 

by  some  that  the  condition  is  a  frequent  concomitant  of 
Bright's  disease.  Cases  have  been  recorded  by  Pitt,^  Allchin,^ 
Hale  White  (a  record  of  eleven  cases), ^  Ormerod  (two  cases),^ 
and  Sharkey  (three  cases). ^ 

This  disease,  while  usually  deemed  of  a  purely  medical 
character,  is  introduced  here  because  surgical  intervention 
seems  a  not  unreasonable  consideration  in  discussing  the  sub- 
ject of  treatment. 

It  is  sufficiently  known  to  surgeons  that  ulceration  on  the 
surface  of  the  body  from  whatever  cause  is  always  greatly 
benefited  by  the  simple  enforcement  of  rest  and  the  local 
applica.tion  of  cleansing  agents.  It  seems  therefore  quite 
reasonable  to  hope  that  if  such  measures  could  be  carried  out 
in  the  case  of  the  large  bowel,  some  improvement  might  be 
looked  for. 

The  initiative  in  this  line  of  treatment  seems  to  have  been 
taken  by  Mayo  Eobson,^  and  to  have  been  carried  out  with 
good  success  in  a  case  which  is  recorded  as  one  of  ulcerative 
or  membranous  colitis.  Various  kinds  of  medical  treatment 
had  been  adopted  without  avail.  An  inguinal  colostomy  was 
then  performed,  and  the  ulcerated  surfaces  of  the  colon  irri- 
gated with  boracic  solution  from  the  anus  to  the  artificial 
opening,  and  vice  versa.  The  patient  was  apparently  cared. 
More  recently  Hale  White  and  Golding-Bird  ^  report  the  suc- 
cessful treatment  by  colostomy  of  a  case  of  membranous  colitis. 

Ulcer  from  obstruction. — As  the  result  of  obstructive  disease, 
whether  due  to  simple  or  malignant  stricture,  ulcers  frequently 
form  in  some  part  of  the  bowel  above  the  obstruction.  The 
commonest  seats  are  immediately  above  the  obstruction  and 
in  the  caecum.  It  is  a  common  occurrence  to  find  in  obstruc- 
tive disease  of  the  sigmoid  flexure  one  or  more  large  ulcers  in 
the  caecum  tending  towards  perforation. 

In  what  particular  way  ulceration  is  caused  is  not  known, 
but  Goodhart  ^  thinks  it  possibly  due  to  one  of  two  influences. 

'  Trans.  Path.  Soc.  Lond.  1885,  vol.  xxxvi.  pp.  199,  209.  =  Ihid. 

^  Guy's  Hospital  Beports,  1888,  3rd  series,  vol.  xxx.  p.  131. 

*  Trans.  Path.  Soc.  Lond.  1889,  vol.  xl.  p.  109. 

*  Ibid.  1891,  vol.  xlii.  p.  109. 

»  Trans.  Clin.  Soc.  Lond.  1898,  vol.  xxvi.  p.  213. 

'  Brit.  Med.  Joum.  1895,  vol.  ii.  p.  1559. 

8  Trans.  Path.  Soc.  Lond.  1880,  vol.  xxxi.  p.  113. 


ULCERATION  437 

'  Either  tlie  over-distension  leads  to  stretching  and  narrowing 
of  the  hlood  channels,  and  so  to  gangrene  ;  or  else  the  material 
retained  acts  as  an  irritant  and  leads  to  ulcerative  inflamma- 
tion.' 

These  ulcers  occasionally  perforate  and  cause  peritonitis. 
If,  however,  adhesions  have  formed  between  the  floor  of 
the  ulcer  and  other  parts,  an  abscess  may  develop  which, 
bursting  externally  through  the  skin,  or  internally  into  another 
portion  of  the  intestinal  canal,  may  result  in  the  formation  of 
a  fistula.  Such  a  result  may,  in  some  instances,  lead  to  more 
or  less  temporary  relief  of  the  obstructive  symptoms. 

In  cases  of  obstruction  from  ftecal  accumulation,  small 
patches  of  mucous  membrane  frequently  necrose,  and  on  sepa- 
ration leave  lesions  which  are  known  as  stercoral  ulcers. 
These  ulcers  vary  in  size  and  number,  and  are  most  frequently 
met  with  in  the  caecum.  By  extension  they  may  lead  to 
chronic  local  peritonitis  with  adhesions,  or  even  perforate  and 
cause  acute  peritonitis.  In  some  cases  they  heal,  and  if  origin- 
ally of  sufficient  size  and  extent,  they  may  result  in  stricture. 
It  is  rarely  possible  to  determine  the  existence  of  stercoral 
ulcers.  The  cause  which  has  given  rise  to  them  generally 
masks  any  symptoms  which  might  otherwise  indicate  their 
existence.  A  sudden  attack  of  acute  pain,  sufficient  to  pro- 
duce prostration,  occurring  in  a  case  of  chronic  constipation 
would  probably  indicate  rupture  or  perforation  of  such  an 
ulcer. 

Ulceration  folloiving  ujjon  lesions  of  the  sjjinal  cord. — In 
deaths  from  fracture  of  the  spine  and  from  pathogenic  lesions 
of  the  cord,  ulcer  has  occasionally  been  found  in  the  large 
bowel.  Targett,  ^  at  the  Pathological  Society  of  London,  showed 
a  specimen  taken  from  a  case  where  death  followed  upon  frac- 
ture, and  alludes  to  cases  observed  in  connection  with  death 
from  disease  of  the  cord. 

Syphilitic  ulcers. — These  are  occasionally  met  with  in  the 
large  bowel,  and  probably  result  from  the  breaking  dow^n  of 
gummata  situated  in  the  submucous  tissue.  Their  commonest 
seat  is  in  the  rectum,  where  their  pathological  features  will 
be  more  fully  described. 

Catarrhal  ?/^^?-s.™ These  are  found  mostly  in  the  colon, 

1   Trans,  1892,  vol.  xliii.  p.  73. 


438  THE   LAEGE   INTESTINE 

and  are  associated  with  an  acute  or  chronic  inflammatory 
condition  of  the  mucous  membrane.  Existing  at  first  as  simple 
isolated  erosions  of  the  surface,  they  may  extend  and  embrace 
considerable  areas  of  surface.  A  form  of  ulceration  known  as 
follicular  is  probably  of  a  character  similar  to,  if  not  the  same 
as,  that  due  to  catarrh  of  the  mucous  membrane.  Associated 
with  this  kind  of  inflammation  is  the  presence  in  some  cases 
of  a  fibrous-like  deposit  on  the  surface  of  the  mucous  mem- 
brane. "Where  this  extends  to  any  degree,  complete  casts  of 
the  bowel  are  found.  The  disease  under  such  circumstances 
is  sometimes  termed  membranous,  pellicular,  or  diphtheritic 
colitis.  Sellew  ^  records  a  case  where,  after  death  from  laryn- 
geal diphtheria,  the  large  bowel  from  the  anus  to  the  ceecum 
was  lined  with  a  membrane  corresponding  to  that  found  lining 
the  larynx  and  pharynx. 


CHAPTER   LIII 

NON-MALIGNANT    OR    CICATRICIAL    STRICTURE 

This  form  of  stricture  owes  its  origin  to  causes  similar  to  those 
which  induce  the  same  condition  in  the  small  bowel.  Inde- 
pendently of  ulceration  it  is  probable  that  no  other  initial 
lesion  exists  for  the  production  of  stenosis.  The  kinds  of  ulcer 
the  healing  of  which  are  liable  to  cause  stricture,  are  the 
tubercular,  the  simple  or  chronic,  the  dysenteric,  and  the 
stercoral.  But  which  of  these  may  be  the  cause  in  any  par- 
ticular case  of  stricture  it  is  often  impossible  to  say,  although 
the  early  history  of  the  case  may  in  some  instances  give  a  clue. 
Thus  an  attack  of  dysentery,  or  evidences,  in  some  form,  of 
tubercular  disease,  or  of  chronic  constipation,  may  indicate  the 
nature  of  the  ulcer  which  has  given  rise  to  the  subsequent 
symptoms  of  stricture. 

Of  thirteen  cases  of  simple  stricture  collected  by  Treves,^ 
eleven  occurred  in  females  and  only  two  in  males.  The 
youngest  patient  was  aged  19  years,  while  the  oldest  was  76 

'  New  York  Medical  Record,  1889,  vol.  xxxv.  p.  444.  ^  Page  286. 


CMCATKICIAL    STIIICTURE  439 

years,  and  the  average  age  of  the  thirteen  cases  44  years.     In 
another  case  ^  subsequently  reported  by  the  same  author,  the 
stricture,  which  was  situated  at  the  junction  of  the  caecum 
and  ascending  colon,  formed  a  hard,  rigid,  circular  ring  which 
just  admitted  the  tip  of  the  little  finger.     The  case  was  that 
of  a  boy  aged  15  years,  who,  for  six  months  previous  to  his 
admission  to  hospital,  had  been  troubled  with  diarrhoea,  fol- 
lowed by  gradually  increasing   constipation  with  colic,  and 
later  with  nausea  and  sickness.     The  symptoms  of  obstruc- 
tion became  more  and  more  marked,  and  the  patient  rapidly 
lost  flesh  and  strength.     Finally  a  comparatively  acute  attack 
supervened,  for  which  the  bowel  was  opened.     Death  ensued 
a  few  hours  after.     I>.  N.  Knox  ^  reported  a  case  of  stricture 
of  the  splenic  flexure  of  the  colon  in  a  woman  aged  49  years. 
Her  symptoms  extended  over  a  period  of  six  weeks,  when  she 
became  suddenly  much  worse  and  died  from  perforation.     In 
a  case  which  I^  have  recorded — that  of  a  girl — an  abscess  in 
the  abdominal  parietes  communicated  with  the  dilated  portion 
of  the  transverse  colon  in  front  of  a  stricture  of  the  splenic 
flexure.      Numerous    strictures  of  varying  tightness  existed 
throughout  the  bowel,  and  also  several  circumferential  ulcers 
in  various  stages  of  cicatrisation. 

There  is  no  constancy  in  the  period  which  intervenes 
between  the  stage  of  ulceration  and  the  resulting  cicatrix,  nor 
in  the  form  of  the  stenosis  which  follows  any  particular  disease. 
In  regard  to  the  former  an  interval  of  months  or  years  may 
exist  between  the  initial  lesion  and  the  symptoms  resulting 
from  subsequent  stricture  ;  while  in  the  latter,  symptoms  of 
obstruction  are  only  likely  to  arise  where  the  preceding  ulcera- 
tion has  extended  for  a  considerable  distance  circumferentially 
round  the  bowel.  Thus  it  happens  that  strictures  of  the  bowel 
are  more  frequent  as  pathological  than  as  clinical  observations. 
In  a  case  recorded  by  Eolleston,^  three  constrictions  were  found 
at  the  post  mortem,  one  just  above  the  caecum,  a  second  at  the 
hepatic  flexure,  and  a  third  in  the  sigmoid  flexure.  The  patient 
had  caries  of  the  spine,  but  was  in  no  way  troubled  with  his 
bowels. 

'   Trans.  Path.  Soc.  Lond,  1888,  vol.  xxxix.  p.  113. 
2  Glasgoiu  Med.  Journ.  1887,  N.S.  vol.  xxviii.  p.  141. 
^  Trans.  Path,  and  Clin.  Soc.  Glasgow,  1892,  vol  iii.  p.  37. 
*  Trans.  Path.  Soc.  Lond.  1890  vol.  xli.  p.  1.31 


440  THE   LAEGE   INTESTINE 

The  very  limited  number  of  cases  recorded  does  not  admit 
of  any  statement  as  to  the  relative  frequency  of  stricture  in 
one  region  as  compared  with  another.  No  part,  from  the 
ileo-csecal  valve  to  the  lower  end  of  the  sigmoid  flexure,  appears 
to  be  exempt. 

Symptoms, — Considerable  variation  exists  in  the  symptoms 
consequent  on  stenosis  of  the  large  bowel.  Thus  it  may  be 
said  that  the  nearer  the  seat  of  stricture  to  the  small  bowel, 
the  more  do  the  symptoms  approach  those  dependent  upon  a 
similar  involvement  of  the  latter ;  while,  on  the  other  hand, 
the  nearer  the  constriction  to  the  lower  end  of  the  sigmoid 
flexure,  the  more  the  symptoms  resemble  those  of  stricture  of 
the  rectam. 

The  earliest  symptom  to  manifest  itself  is  usually  consti- 
pation, which,  as  it  increases,  frequently  requires  the  use 
of  purgatives.  The  motions  are  usually  well  formed,  any 
alteration  in  shape  indicates  a  stricture  low  down  in  the 
rectum.  Associated  with  the  need  of  relief  are  attacks  of 
paroxysmal  or  colicky  pains,  which  subside  so  soon  as 
the  bowel  is  unloaded.  Not  infrequently  a  temporary  attack 
of  diarrhoea  supervenes  upon  the  relief  of  the  distended 
bowel. 

Sooner  or  later  an  attack  of  obstruction  ensues,  with  an 
aggravation  of  those  symptoms  which  have  only  been  pre- 
viously suffered  from  to  a  slight  degree.  Thus  the  paroxysmal 
pain  becomes  more  marked  and  more  frequent.  Aperients 
may  intensify  rather  than  diminish  the  pain.  Tenesmus 
exists  in  some  cases ;  while  vomiting,  limited  at  first  to  the 
contents  of  the  stomach,  may  or  may  not  prove  a  prominent 
feature.  The  abdomen  is  noticed  to  distend,  partly  as  the 
result  of  accumulated  flatus  and  partly  owing  to  fsecal  disten- 
sion of  the  intestine  above  the  stricture.  The  abdominal 
parietes  are  flaccid,  and,  if  thin,  may  admit  of  palpation  of 
the  distended  gut.  More  particularly  does  a  loaded  colon 
become  perceptible  when  the  stricture  is  situated  low  down  in 
the  sigmoid  flexure.  During  the  attacks  of  paroxysmal  pain, 
the  vermicular  action  of  the  walls  of  the  distended  small 
intestine  may  become  visible.  This  state  of  things  may  last 
for  some  days,  when  sudden  relief  of  the  intestine,  through 
the  passage  of  a  large  and  copious  motion,  will  cause  all  the 


CICATRICIAL    STiilCTUKE  441 

symptoms  to  subside,  and  the  patient  may  then  fur  a  period 
return  to  a  state  of  comparative  well-being. 

After  a  variable  interval  of  time,  either  as  the  result  of 
some  indiscretion  in  diet  or  from  increased  narrowing  of  the 
strictured  channel,  another  attack  of  obstruction  ensues,  with 
a  repetition  of  all  the  previous  symptoms.  The  completeness 
of  the  obstruction  in  this  renewed  attack  may  have  caused 
the  case  to  enter  upon  its  last  and  fatal  stage.  The  vomiting 
may  now  assume  a  stercoraceous  character,  and  the  pain, 
hitherto  paroxysmal,  become  continuous.  Death  is  some- 
times ushered  in  by  peritonitis. 

The  general  condition  of  the  patient  is  usually  one  of 
gradually  increasing  weakness  and  emaciation.  This,  how- 
ever, is  not  so  marked  in  the  earlier  stages  of  the  disease. 
But  repeated  attacks  of  obstruction  soon  undermine  the 
health  and  strength. 

While  the  above  may  be  taken  as  an  example  of  the 
symptoms  to  be  met  with  in  a  fairly  typical  instance,  the 
following,  reported  by  Bartolome,^  will  illustrate  how  variable 
they  may  prove,  even  in  a  case  which  ends  fatally.  The 
patient,  a  female  aged  51  years,  had  had  several  attacks 
of  complete  constipation  ;  but  these  usually  passed  off  after  a 
few  days  and,  beyond  slight  abdominal  pain,  caused  her  but 
little  inconvenience.  In  her  last  attack,  which  lasted  nineteen 
and  a  half  days  before  death  ensued,  she  only  suffered,  in 
addition  to  her  complete  constipation,  from  a  little  bilious 
vomiting.  This,  however,  on  one  occasion  only,  and  that  two 
days  before  death,  consisted  in  a  copious  stercoraceous  ejection 
which  was  not  repeated.  The  rectum  was  extremely  patulous, 
with  some  prolapse,  and  admitted  the  introduction  of  the 
hand.  She  gradually  sank.  At  the  post  mortem,  a  stricture 
was  found  at  the  junction  of  the  sigmoid  flexure  and  the 
rectum. 

Case  XC. — Simple  stricture  of  the  sigmoid  flexure , 
A  man  aged  45  years  had  for  two  and  a  half  years  or  more  suffered 
from  habitual  constipation,  which  la,tterly  had  necessitated  the  use  of 
purgatives.  Diarrhoea  at  times  followed  the  use  of  aperients.  Prior  to 
the  action  of  the  bowels  he  suffered  from  griping  and  cohcky  pains,  with 
a  dull  aching-  about  the  lower  part  of  the  lumbar  regions,  and  after  move- 

'  Brit.  Med.  Journ.  J886,  vol.  i.  p.  190. 


442  THE    LARGE   INTESTINE 

ment,  pain  and  soreness  in  the  abdomen  was  felt  for  a  couple  of  hours. 
At  times  the  motions  contained  quantities  of  red  or  clear  gelatinous 
mucus.  Before  movement  the  distended  descending  colon  and  sigmoid 
flexure  could  be  made  out,  the  manipulation  causing  some  feeling  of  tender- 
ness. He  suffered  at  times  from  flatulence  and  abdominal  distension. 
Pain  sometimes  followed  a  meal,  and  on  more  than  one  occasion  indis- 
cretion in  diet  led  to  an  attack  of  obstruction,  with  peritonitis.  He  learnt 
to  relieve  himself  by  using  injections  of  water.  On  the  last  occasion, 
however,  he  appears  to  have  injected  either  too  much  or  too  forcibly,  for 
rupture  of  the  bowel  occurred  immediately  below  the  stricture,  and  death 
followed.  At  the  post  mortem,  old  adhesions  were  found  binding  down 
the  rectum,  sigmoid  flexure,  and  descending  colon.  The  descending  colon 
above  the  stricture  was  packed  with  fgeces.  The  stricture  itself  admitted 
a  No.  10  catheter.  The  rupture  was  principally  below  the  stricture,  but 
involved  it  also.  The  cause  of  the  stricture,  so  far  as  could  be  made  out, 
appeared  to  have  been  a  simple  ulcer.  (J.  P.  Doyle,  '  Trans,  of  the  Eoyal 
Academy  of  Medicine  in  Ireland,'  1892,  vol.  x.  p.  81.) 

Diagnosis. — The  symptoms  of  stricture  of  the  large  intes- 
tine sometimes  so  closely  resemble  those  of  the  small  that 
differentiation  becomes  all  but  impossible.  Where,  however, 
a  distinction  can  be  drawn,  it  will  be  found  probably  to  exist 
in  one  or  other  of  the  following  details. 

Attacks  of  obstruction  of  the  large  bowel  are  less  acute. 
Vomiting  is  not  such  a  prominent  symptom,  and  is  much 
longer  in  becoming  faecal.  Food  rarely  causes  an  attack  of 
pain,  and  is  not  necessarily  followed  by  vomiting.  Abdominal 
distension  is  more  marked,  and  the  peristaltic  action  of  the 
bowel  usually  visible.  Aperients  augment  rather  than 
diminish  the  pain.  Complete  obstruction  is  much  longer  in 
bringing  about  a  fatal  result. 

In  distinguishing  between  symptoms  connected  with 
stricture  of  the  large  bowel  and  those  dependent  on  stenosis 
of  the  rectum,  not  so  much  difficulty  exists,  inasmuch  as  the 
rectum  admits  of  more  or  less  complete  examination  by 
mechanical  means.  The  exact  seat  of  a  stricture  it  is  not 
usually  possible  to  determine,  except  when  it  is  located  in  the 
sigmoid  flexure.  In  this  region  the  injection  of  water  per 
rectum  ma}^  according  to  the  amount  introduced,  convey 
some  idea  as  to  its  situation.  It  must,  however,  be  remem- 
bered that  the  fluid  may  find  its  way  through  the  stricture, 
and  so  mislead  rather  than  guide.  Another  symptom,  of 
which   more  will   be    said  when   discussing  stricture  of  the 


ClCATPtlCIAL    STRICTURE  443 

rectum,  is  the  so-called  'ballooning'  of  the  bowel  below  the 
obstruction  ;  that  is  to  say,  the  rectum  becomes  widely  dilated 
from  within  the  anus  upwards. 

Treatment. — Eelief  of  the  earlier  symptoms  will  be  best 
effected  by  a  careful  attention  to  diet  and  proper  regulation 
of  the  bowel  by  the  administration  of  mild  aperients.  As 
the  stricture  tightens  and  temporary  attacks  of  obstruction 
supervene,  the  use  of  copious  enemata  will  likely  afford 
the  readiest  relief.  Violent  purges  should  be  avoided  ;  and, 
failing  any  beneficial  result  from  the  use  of  simple  aperients, 
the  opposite  treatment  of  rest  to  the  bowel,  by  giving  belladonna 
and  opium,  should  be  tried.  When  all  conservative  measures 
fail,  there  is  nothing  but  operation  to  afford  relief.  The 
bow^el  must  be  opened  above  the  stricture  by  a  right  or  left 
colostomy,  according  to  the  situation  of  the  obstruction  ;  and 
if  a  left  inguinal  or  lumbar  colostomy  shows  the  bowel  to 
be  collapsed,  the  wound  should  be  closed  and  the  ascending 
colon  opened.  When  the  stricture  is  seated  in  the  caecum  or 
at  the  ileo-csecal  valve,  enterostomy  must  be  performed. 
Pean  '  has  succeeded  in  two  cases  of  simple  stricture  of  the 
ileo-caecal  valve  by  performing  enteroplasty,  an  operation 
similar  to  the  pyloroplasty  of  Heineke  and  Mikulicz.  After 
withdrawing  the  part  and  clamping  both  ends  of  the  bowel, 
the  stricture d  valve  was  divided  in  the  long  axis  of  the  gut, 
and  the  edges  of  the  wound  so  formed  united  transversely. 
For  any  further  operative  measures  upon  the  stricture  itself, 
what  has  been  said  on  this  point  in  the  case  of  stricture  of 
the  small  intestine  might  be  repeated  here. 

It  need  hardly  be  indicated  that  where  there  is  just  reason 
to  believe  that  a  patient,  in  the  early  stage  of  the  disease,  is 
suffering  from  simple  stricture  of  the  large  bowel,  early 
operative  intervention  holds  out  the  best  and  possibly  the 
only  hope  of  an  ultimate  cure. 

'  Annual  of  the  Universal  Medical  Sciences,  1892,    ol.  iii.  C-  69. 


444  THE   LARGE   INTESTINE 


CHAPTER   LIV 

INTERNAL    STRANGULATION.       ADHESION,    AND    KINKING. 
INTUSSUSCEPTION.       VOLVULUS 

The  size,  situation,  and  fixity  of  the  large  intestine  render  it 
peculiarly  exempt  from  many  of  those  sources  so  prone  to 
strangalate  the  small  bowel.  Treves  ^  quotes  a  case  recorded 
by  Trelat,  where  the  sigmoid  flexure  became  strangulated 
through  a  slit  in  the  mesentery ;  and  Bennett  ^  describes  a 
case  of  strangulation  of  part  of  the  ascending  colon,  together 
with  the  ileum,  beneath  an  appendix  which  had  become 
adherent  to  the  right  ovary.  The  patient  in  this  case  had 
also  a  stricture  of  the  rectum  which  would  only  admit  the 
point  of  the  finger,  and  a  fistulous  communication  above  the 
stricture  with  the  vagina. 

As  regards  internal  hernia,  the  only  situation  where  the 
large  bowel  appears  to  have  been  strangulated  is  through  an 
opening  in  the  diaphragm.  In  most  instances,  if  not  in  all, 
the  bowel  has  passed  through  a  congenital  aperture  either 
alone  or  in  conjunction  with  the  stomach  and  other  viscera. 

The  cases  recorded  are  very  few.  Smith  ^  reports  the  case 
of  a  child,  2  months  old,  who  had  suffered  from  attacks  of 
abdominal  pain,  each  of  which  was  followed  by  a  state  of  great 
prostration.  The  attacks  of  pain  came  on  at  first  every  other 
day,  but  later  much  more  frequently,  until  death  followed  from 
exhaustion.  At  the  post  mortem,  it  was  found  that  in  the 
ligamentum  arcuatum  externum  there  was  a  rounded  opening 
of  about  an  inch  in  diameter.  Through  this  aperture  had 
passed,  into  the  left  side  of  the  thorax,  the  ascending  colon, 
the  transverse,  the  descending,  and  half  of  the  sigmoid 
flexure.  Schwartz  and  Rochard  ^  record  a  case  where  the 
patient  presented  all  the  typical  signs  of  acute  intestinal 
obstruction.  Laparotomy  was  performed,  and  a  careful 
examination  of  the  abdomen  made,  but  nothing  detected.    The 


'  Page  53.  '  Trans.  Path.  Soc.  Lond.  1853,  vol.  iv.  p.  146. 

'  Archives  of  Pediatrics,  1887,  vol.  iv.  p.  385. 
*  Bevue  de  Chirurgie,  1892,  vol.  xii.  p.  756. 


IXTETiXAL    STILVNGULATIOX  44;", 

patient  died,  and  at  the  post  mortem  a  loop  of  bowel  formed 
by  the  transverse  and  descending  colon  was  fomid  to  have 
passed  through  and  become  strangulated  by  an  aperture  in 
the  diaphragm.  In  a  case  of  my  own,  fully  reported  below, 
the  symptoms  also  were  those  of  acute  intestinal  obstruction. 
In  this  instance  the  splenic  flexure  of  the  colon  was  nipped  in 
an  aperture  in  the  left  expansion  of  the  diaphragm.  Through 
this  aperture  had  passed  a  mass  of  omentum,  which  from  its 
organic  connection  with  the  subpleural  tissue  seemed  to  indi- 
cate that  the  incarceration  had  existed  for  some  time.  The 
only  clinical  feature  which  could  be  said  to  have  thrown  any 
true  light  upon  the  na  ture  of  the  obstruction  was  the  sausage- 
shaped  tumour  felt  in  the  epigastric  and  left  hypochondriac 
regions.  This,  however,  proved  in  reality  to  be  a  misleading 
factor  in  the  diagnosis,  as  it  naturally  led  to  the  belief  that 
the  tumour  was  an  intussusception.  The  operation  showed  it 
to  be  the  distended  transverse  colon  passing  upwards  to  the 
diaphragmatic  aperture. 

Case  XCI. — Strangulated  diaphragmatic  hernia :    symptoms  of  acute 

intestinal   obstruction :    laparotomy.      Death.      (Abstract    of  report 

taken  by  Dr.  Alexander  MacLennan.) 

J.  M.,  a  schoolboy  aged  8  years,  was  seized  with  vomiting  on  Thursday 
night,  October  31 ,  1895,  shortly  after  having  eaten  some  nuts  and  apples. 
He  suffered  no  abdominal  pain  at  the  onset.  The  following  day,  Friday, 
he  was  given  some  castor  oil,  which  he  vomited.  He  continued  to  vomit 
everything  he  took  on  Saturday  and  Sunday.  On  Tuesday  evening  his 
vomiting  became  faecal.  Neither  flatus  nor  faeces  passed  during  these 
days.  There  was  no  history  of  previous  disease  of,  or  injury  to,  the  abdomen. 

He  was  admitted  into  the  Victoria  Infirmarj',  under  the  care  of  Mr. 
Maylard,  at  7.15  p.m.  on  Wednesday,  November  6 — that  is,  on  the  sixth 
day  of  his  symptoms.  The  boy,  when  seen,  was  in  a  somewhat,  though 
not  markedly,  collapsed  condition,  with  rapid  and  feeble  pulse.  He  com- 
plained of  pain  in  the  left  hypochondriac  region,  where  tenderness  on 
palpation  was  also  elicited.  The  pain,  he  stated,  commenced  in  the  left 
inguinal  region  and  was  spasmodic  in  character.  The  colon  was  evidentiv 
distended,  as  also  was  the  whole  abdomen.  Nothing  was  detected  by 
rectal  examination,  and  no  blood  stain  seen  on  withdrawal  of  the  finger. 

Operation. — At  8.15  p.m.,  an  hour  after  his  admission,  laparotomy  was 
performed.  Prior  to  opening  the  abdomen,  the  parts  were  palpated,  when 
a  very  well-defined  sausage-shaped  tumour  could  be  felt  in  the  epigastric 
region,  tapermg  off  somewhat  towards  the  right  hypochondriimi,  but 
ending  abruptly  when  traced  to  the  left.  On  opening  the  peritoneal  cavity, 
distended  small  bowel  presented.  On  tracing  this  it  was  found  to  lead  1o 
the  caecum.     This,  with  the  large  intestine  as  far  as  the  splenic  flexure, 


446  THE    LARGE   INTESTINE 

was  enormously  distended.  At  this  latter  point  the  bowel  took  a  course 
upwards  and  a  little  backwards  to  the  left.  Passing  up  in  the  same  direc- 
tion was  seen  the  collapsed  descending  colon.  Examination  with  the 
finger  then  revealed  the  presence  of  a  small  aperture  through  which  the 
bowel  appeared  to  pass.  No  traction  on  the  latter  would  release  the 
intestine  until  the  aperture  was  dilated.  This  was  effected  by  gradually  in- 
sinuating the  finger  through  it,  the  bowel  then  becoming  easily  disengaged. 
On  dilating  the  anus,  gas  and  fluid  faeces  at  once  began  to  escape.  The 
distended  colon  was  partially  relieved  by  puncturing  with  the  trocar  ;  but 
the  bowel  wall  appeared  lax,  and  paralysed  from  prolonged  over-distension. 
The  intestines  were  returned  and  the  abdomen  closed.  The  boy  rallied 
and  lived  for  about  twelve  hours,  when  he  died  from  exhaustion.  There 
was  a  free  evacuation  from  the  bowel  during  the  night. 

Post  7nortem,  by  Dr.  T.  K.  Monro. — An  opening,  three-quarters  of  an 
inch  in  diameter  and  circular  in  shape,  was  found  in  the  left  leaf  of  the 
diaphragm,  close  to  the  left  lateral  parietes  and  about  on  a  level  with  the 
eighth  rib.  The  diaphragm  bounded  it  all  round.  A  cord  of  omentum 
passed  through  from  the  cardiac  end  of  the  stomach.  The  omental  mass 
turned  inwards  on  the  upper  surface  of  the  diaphragm  and  became  em- 
bedded in  the  subpleural  connective  tissue,  with  which  it  was  very  closely 
incorporated :  appearances  suggested  an  old-standing  omental  hernia. 
Both  lungs  were  adherent.  No  corresponding  opening  was  seen  on  the 
opposite  side.  (Plate  XIX,  fig.  57.)  (A.  Ernest  Maylard,  '  Glasgow  Med. 
Journ.'  1896,  vol.  xlvi.  p.  143,  and  '  Path,  and  Clin.  Soc.  Trans.  Glasgow,' 
vol.  vi.  p.  78.) 

Adhesions. — Adhesions  involving  the  large  bowel  to  vari- 
able degrees  are  common  enough,  but  it  is  comparatively 
rare  for  such  adhesions  to  cause  obstruction  similar  to  tbat 
which  is  not  infrequently  met  with  in  the  case  of  the  small 
intestine. 

The  causes  which  give  rise  to  these  adhesions  are  mostly 
similar  to  those  already  described  as  affecting  the  small  intes- 
tine, and  are  directly  due  to  local  attacks  of  peritonitis.  The 
commonest  cause,  however,  which  originates  within  the  large 
intestine,  is  in  all  probability  some  form  of  ulceration.  When 
the  ulcer  has  extended  so  deeply  that  its  base  is  formed  by 
little  else  than  peritoneum,  inflammation  attacks  the  latter, 
and  adhesions  form  between  the  bowel  and  some  neighbour- 
incy  tissue  or  organ.  As  a  further  result  of  such  a  connection, 
tistulge  may  become  established  with  some  other  viscus,  or  an 
abscess  may  form. 

Kinking. — The  attachment  and  position  of  the  large  in- 
testine render  it  specially  exempt  from  any  acute  bending. 
Instances,  however,  occasionally  occur  where  it  seems  probable 


PLATE    XIX. 


Fig.  57.— Diaphragmatic  Hernia. — a.  ribs;  b,  margin  of  aperture  in  abdominal 
aspect  of  diaphragm  ;  c  c' ,  incarcerated  omentum  passing  through  dia- 
phragmatic aperture  into  subpleura!  tissue.     {V.I.M.,  Glas.) 


IXTUSSUSCl'PTIOX  447 

that  enormous  distension  of  the  colon  maybe  Uie  result  of 
some  undue  flexion  of  the  sigmoid  flexure  at  its  junction  with 
the  rectum.  Kinking  from  adhesions,  resulting  in  obstruction, 
is  very  rare.  A  case  of  the  kind  is  recorded  by  Shaw.^  The 
patient  died  of  acute  obstruction,  and  at  the  post  mortem  the 
following  condition  was  found.  Tracing  the  ascending  colon 
to  its  highest  point,  it  was  seen  to  return  abruptly  upon  itself 
and  then  descend  downwards  as  far  as  the  c^cum,  and  the 
two  portions  lying  parallel  were  firmly  united  by  lymph  to 
each  other  and  the  adjoining  parts.  After  forming  this  loop, 
the  colon  ascended  and  followed  its  usual  course.  The  internal 
surface  of  the  colon  was  extensively  ulcerated,  and  a  little 
beyond  the  caecum,  at  a  point  where  a  fold  of  jejunum  adhered, 
a  fistulous  communication  existed  between  the  two  coils. 

Another  case  is  recorded  by  McNutt,^  in  which  the  colon 
was  found  distended  to  the  size  of  a  coat  sleeve,  the  occlusion 
being  due  to  a  kink  in  the  intestine  caused  by  adhesions  fol- 
lowing peritonitis. 

Intussusception.— Invagination  of  one  part  of  the  colon  into 
another — that  is  to  say,  the  colic  variety  of  intussuscej)tion — 
is  rare.  Out  of  twenty -seven  cases  of  intussusception  collected 
by  Bull  and  Cohen,^  which  were  reported  during  the  year  ]  894, 
one  only  was  colic.  Cases,  however,  are  recorded  from  time  to 
time,  and  from  these  it  would  appear  that  the  condition  is 
most  frequently  met  with  in  adults,  and  usually  owes  its  cause 
to  some  definite  local  stimulus,  such  as  is  furnished  by  a 
tumour  or  stricture.  Two  cases  are  reported  by  Bryant,^  in 
both  of  which  the  apex  of  the  intussusceptum  had  a  large 
papillomatous  growth  attached  to  it.  In  two  other  cases 
referred  to  by  the  same  author,  the  intussusception  was  asso- 
ciated with  malignant  disease  of  the  bowel.  In  another  case, 
recorded  by  Mayo  Eobson,"^  the  apex  of  the  intussuscej)tum  was 
formed  by  a  carcinomatous  stricture  of  the  descending  colon  ; 
and  in  a  somewhat  similar  case,  reported  by  Symonds,*'  the 
malignant  growth  was  situated  in  the  sigmoid  flexure. 

•  Trans.  Path.  Soc.  Loncl.  1853,  vol.  iv.  p.  147. 

2  Anmial  of  the  Universal  Medical  Sciences,  1892,  vol.  iii.  C — 60. 
»  Ibid.  vol.  iii.  C— 24. 

*  Trans.  Mcd.-Chir.  Soc.  Land.  1894,  vol.  Ixxvii.  p.  169. 

=  Brit.  Med.  Journ.  1895,  vol.  ii.  p.  963.  '  Ibid.  1893,  vol.  i.  p.  C38. 


448  THE   LARGE   INTESTINE 

The  intussusception  is  almost  always  of  the  descending 
variety.  An  exceptional  instance,  however,  is  recorded  by 
Power,'  where  it  was  of  the  ascending  form.  In  this  case  the 
patient  had  an  ordinary  ileo-caecal  intussusception,  and  in 
addition  a  second  invagination,  about  an  inch  and  a  half  in 
length,  situated  in  the  transverse  colon.  That  this  latter, 
■which  was  of  the  ascending  variety,  existed  before  death,  was 
proved  by  the  contiguous  walls  of  the  gut  being  glued  together 
by  recent  lymph.     Two  other  similar  cases  are  referred  to. 

Symptoms. — As  distinguished  from  the  other  forms  of 
intussusception,  the  symptoms  associated  with  the  purely  colic 
variety  are  much  less  sudden  in  their  onset  and  much  less 
rapid  and  acute  in  their  progress. 

In  most  of  these  cases  the  patients  have  suffered  previously 
from  attacks  of  colic,  constipation  or  diarrhoea,  vomiting,  and 
other  symptoms  indicative  of  temporary  obstruction  or  in- 
testinal irritation.  But  in  those  cases,  and  they  comprise  the 
majority,  where  prior  to  the  formation  of  the  intussusception 
there  exists  an  innocent  tumour  or  a  malignant  growth,  the 
earlier  symptoms  may  be  more  intimately  connected  with  such 
lesions.  It  is  usual,  however,  for  the  invagination  to  take 
place  gradually,  and  so  attacks  of  obstruction  may  occur  from 
time  to  time  as  the  direct  result  of  such  a  process. 

When  the  intussusception  becomes  a  marked  feature  in 
the  case,  it  frequently  projects  into  the  rectum,  and  is  some- 
times protruded  through  the  anus.  In  such  cases  it  is  possible 
both  to  feel  and  probably  see  the  tumour.  Tenesmus  with 
the  passage  of  blood  and  mucus  then  become  pathognomonic 
sjmptoms.  Further,  the  typical  sausage- shaped  tumour  may 
be  felt  in  the  left  iliac  fossa  or  in  some  other  region  of  the 
abdomen. 

Complete  blockage  of  the  canal  occasionally  occurs,  and 
when  it  does  so,  vomiting  setsin,  with  distension  of  the  abdomen 
and  other  symptoms  of  acute  intestinal  obstruction. 

Diagnosis. — As  in  the  case  of  other  forms  of  intussuscep- 
tion, the  presence  of  a  sausage-shaped  tumour  in  the  iliac 
fossa,  or  felt  within  the  rectum,  together  with  tenesmus  and 
the  passage  of  blood  and  mucus,  are  pathognomonic  sym- 
ptoms of  the  condition. 

'   Trans,  rath.  Soc.  Lond.  1886,  vol.  xxxvii.  p.  240. 


VOLVULUS  449 

The  chief  distmguishing  features  between  this  form  of  in- 
tussusception and  those  where  the  smah  intestine  is  involved 
are,  the  age  of  the  patient,  the  history  of  antecedent  bowel 
trouble,  and  the  comparatively  non-acute  progress  of  the 
affection.  The  detection  also  of  a  polypus  or  some  malignant 
growth,  forming  the  apex  of  the  intussusceptum,  is  almost 
equally  distinctive  of  involvement  of  the  large  bowel. 

Prognosis. — There  is  little  to  hope  for  without  surgical  in- 
tervention ;  this  is  the  more  true  when  the  ca.use  is  some 
kind  of  tumour.  A  case,  however,  is  reported  by  Satcliffe  ' 
where  a  boy  aged  17  years,  after  suffering  for  seventeen  days 
from  symptoms  of  obstruction  of  variable  and  intermittent  de- 
grees of  acuteness,  passed  a  sphacelus  of  bowel  thirteen  inches 
in  length,  seven  inches  of  which  represented  intact  bowel,  while 
the  remaining  six  inches  consisted  of  a  ribbon  of  only  half  of 
the  circumference  of  the  gut.  The  presence  of  unmistakable 
appendices  epiploicse  proved  it  to  be  large  intestine.  Such 
an  instance  of  natural  recovery  is  quite  exceptional ;  in  most 
cases  death  will  supervene  before  such  time  has  elapsed  as 
will  admit  of  the  natural  separation  of  the  intussusceptum. 

Treatment. — Each  case  will  need  to  be  dealt  with  on  its 
own  merits.  In  the  two  cases  reported  by  Bryant,  success 
was  obtained  by  first  forcibly  dilating  the  anus,  removing  the 
papillomatous  growth,  and  then  with  the  hand  inserted  into 
the  rectum,  pushing  up  the  bowel.  It  is  possible  that  many 
surgeons  do  not  possess  a  hand  which  measures  circumferenti- 
ally  nine  and  a  quarter  inches  over  the  knuckles,  in  which  case 
injection,  inflation,  or  some  other  simple  mechanical  measure 
for  pushing  up  the  bowel  must  be  tried.  In  the  case  reported 
by  Sjmonds,  the  malignant  stricture  was  excised,  and  the  bowel 
then  successfully  pushed  up.  In  Mayo  Eobson's  case  laparotomy 
was  performed  and  the  intussusception  easily  reduced  by  pres- 
sure from  below.  The  tumour  was  then  successfully  excised. 
Volvulus. — Twists  are  more  frequently  met  with  in  the 
large  bowel  than  in  the  small ;  the  predisposing  causes 
are,  however,  much  the  same  in  both.  Either  there  is  a 
congenital  malformation  in  the  form  of  an  abnormally  long 
meso-colon,  or  this  latter  has  become  elongated  owing  to  con- 
tinuous overloading  of  the  bowel,  such  as  is  liable  to  occur 

'  Brit.  Med.  Joiini.  1894,  vol.  ii.  p.  124. 

G  O 


450  THE   LARGE   IKTESTITsE 

in  some  cases  of  chronic  constipation.  Old  adhesions  may 
also  in  some  instances  prove  the  initial  cause.  In  a  case 
reported  by  Bonuzzi,'  it  would  appear  that  the  excessive 
length  of  the  sigmoid  flexure — four  times  its  usual  size — had 
predisposed  to  rotation  on  its  mesenteric  axis.  Among  the 
most  important  direct  or  exciting  causes  are  irregular  dis- 
tribution of  the  intestinal  contents  and  violent  peristalsis. 

As  regards  the  seat  of  the  volvulus,  the  segment  most 
often  implicated  is  the  sigmoid  flexure,  and  next  to  that  the 
caecum  ;  the  transverse  colon  is  but  rarely  affected.  The 
twisting  of  any  part  may  take  place  in  one  of  three  ways  :  the 
bowel  may  rotate  on  its  own  axis,  intertwine  with  another 
portion,  or  twist  about  an  axis  formed  by  its  mesentery.  In 
a  case  reported  by  Walsham,^  '  the  csecum  and  the  beginning 
of  the  colon  were  twisted  three  times  from  right  to  left  around 
the  lower  four  inches  of  the  ileum,  forming  a  corkscrew-like 
coil,  with  the  caecum  at  the  apex.' 

Volvulus  is  more  frequently  met  with  in  males  than  in 
females,  and  usually  occurs  after  middle  life. 

The  result  of  twisting  is  to  cause  obstruction,  and  certain 
changes  within  the  affected  portion.  As  regards  obstruction, 
the  more  complete  the  twist  the  more  complete  the  blockage. 
When  a  loop  of  bowel  rotates  on  its  mesentery,  obstruction  is 
likely  to  be  of  an  acuter  character  than  when  it  revolves  upon 
its  own  axis. 

The  effect  of  a  twist  upon  the  involved  parts  depends 
upon  its  form  and  the  degree  of  rotation.  When  a  loop  of 
bowel  rotates  upon  its  mesenteric  axis  to  more  than  a  half- 
turn,  the  mesenteric  vessels  become  strangulated,  and  the 
loop  rapidly  gets  congested,  dilates,  and  subsequently  becomes 
gangrenous.  Adhesions  are  formed  and  general  peritonitis 
sooner  or  later  sets  in.  The  distension  of  the  involved  loop  is 
sometimes  considerable.  In  a  case  referred  to  by  Wilks  and 
Moxon  ^  the  loop  reached  the  under  surface  of  the  diaphragm. 
The  bowel  above  the  volvulus  also  becomes  distended. 

Symptoms. — The  symptoms  are  usually  those  of  acute 
obstruction,  with  certain  features  which  sometimes  render  it 
possible  to  diagnose  the  true   cause.      Thus   an   important 

'  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  i.  D — 32. 

2  Trans.  Clin.  Soc.  Land.  1888,  vol.  xxi.  p.  139.        ^  Patliolocjy,  p.  397. 


VOLVULUS  4.51 

early  pliysieal  sign  is  a  circumscribed  area  of  tympanites,  which 
corresponds  to  the  distended  loop  involved,  the  remaining 
portion  of  the  abdomen  being  more  or  less  dull  to  percussion. 
When  the  volvulus  is  situated  in  the  sigmoid  segment,  vomiting 
is  not  usually  a  constant  symptom.  Colicky  pains  are  com- 
plained of  from  the  first ;  and  general  abdominal  distension 
becomes  a  marked  feature  at  a  later  stage. 

Case  XCIL — Volvulus  of  the  sigmoid  flexure,  successfully  reduced  after 

lajparotpniy. 
Mrs.  M.,aged  50  years,  insane,  had  suffered  from  chronic  constipation. 
She  was  suddenly  seized  with  vomiting  and  symptoms  of  acute  obstruc- 
tion of  the  bowels.  There  was  tympanites,  a  quick  pulse  and  moderate 
elevation  of  temperature.  On  the  evening  of  the  third  day,  she  lay  in  bed 
with  her  knees  drawn  up,  her  face  pinched,  and  expression  anxious.  Pulse 
114.  Temperature  100°.  Her  abdomen  was  exceedingly  distended,  espe- 
cially in  the  centre,  where  there  was  a  peculiar  ovoid  enlargement  of  great 
size.  Later  on,  the  same  evening,  laparotomy  was  performed,  and  on 
opening  the  abdomen  a  huge  distended  viscus  at  once  presented.  It  was 
at  first  thought  to  be  a  greatly  distended  stomach,  but  was  recognised  as 
the  colon  by  its  glandulae  epiploicae  and  longitudinal  bands.  An  incision 
was  made  into  it,  and  a  large  quantity  of  gas  and  some  fluids  escaped, 
sufficient  to  relieve  the  distension  and  allow  careful  examination,  which 
showed  one  complete  turn  of  the  sigmoid  upon  itself  from  left  to  ricrht. 
The  remaining  part  of  the  colon  and  small  intestines  was  but  moderately 
distended.  The  confined  part  of  the  sigmoid  flexure  was  dark  and  con- 
gested, it  having  furnished  the  greater  part  of  the  previous  abdominal 
distension.  A  few  Lembert  sutures  closed  the  incised  bowel,  and  reduction 
with  replacement  was  with  moderate  difficulty  accomplished.  As  soon 
as  the  patient  had  recovered  from  the  anaesthetic  ten  grains  of  calomel 
were  administered,  followed  in  a  few  hours  by  profuse  discharge  from 
the  bowels  and  an  uneventful  recovery.  (William  J.  Mayo,  '  Annals  of 
Surgery,'  1893,  vol.  xviii.  p.  28.) 

Treatment.— When  seen  within  a  few  hours  of  the  onset 
of  acute  symptoms,  copious  injections  of  water  should  be  given 
with  the  object  of  emptying  the  lower  bowel,  and,  if  possible, 
untwisting  the  involved  loop  through  distension  of  its  canal. 
Massage,  after  the  plan  advised  by  Hutchinson,  may  also  be 
practised.  These  measures,  however,  failing,  or  as  a  primary 
resource  in  cases  at  a  later  stage,  the  abdomen  must  be  opened. 

The  incision,  made  in  the  median  line,  below  the  umbilicus, 
must  be  of  sufficient  length  to  admit  of  the  volvulus  being 
brought  outside  the  wound.  If  the  bowel  has  not  become 
gangrenous  its  distension  must  be  relieved  by  a  longitudinal 


452  THE   LARGE   INTESTINE 

incision  an  inch  or  so  in  length.  This  will  admit  of  the  escape 
of  gas  and  fgeces,  and  all  due  care  must  be  taken,  in  the  suitable 
arrangement  of  cloths  &c.,  to  prevent  any  contamination  of 
the  peritoneum  with  the  outflowing  faeces.  The  opening  in  the 
gut  must  be  closed  by  Lembert  stitches ;  and  after  rectifying 
the  position  of  the  bowel,  the  parts  are  returned  into  the 
abdominal  cavity  and  the  parietal  wound  clospd. 

Id  some  cases  it  may  happen  that  considerable  distension 
of  the  colon  and  intestines  above  co-exists  and  interferes  with 
the  replacement  of  the  untwisted  loop.  It  will  then  be  neces- 
sary to  relieve  the  distension  of  these  parts  in  a  similar  way 
to  that  adopted  in  the  case  of  the  loop  itself. 

It  occasionally  happens  that  recurrence  takes  place ;  as 
shown,  for  instance,  in  a  case  reported  by  Finney,^  where  three 
years  after  the  first  operation  a  second  had  to  be  performed 
for  a  repetition  of  the  same  condition.  In  order  to  prevent 
such  recurrence,  therefore,  Eoux  ^  recommends  that  in  case  of 
sigmoid  volvulus  the  meso -colon  should  be  sutured  to  the 
abdominal  wall.  In  a  case  mentioned  by  Gould, ^  the  wall  of 
the  gut  itself  was  stitched  to  the  parietes. 

When  the  bowel  has  become  gangrenous,  or  adhesions  have 
formed,  so  that  it  is  neither  safe  nor  possible  to  attempt  re- 
placement, further  measures  must  be  adopted.  In  the  former 
case  excision  of  the  volvulus  is  necessary ;  while  in  the  latter, 
intestinal  anastomosis  must  be  established. 

Of  successful  cases  treated  by  laparotomy  the  following 
may  be  given.  McArdle  "*  reports  having  with  difficulty  un- 
twisted the  sigmoid  after  incising  it  and  washing  out  the  canal 
with  warm  water.  Senn,^  Mayo,  Ochsner,  and  Finney^  have 
also  published  successful  cases.  Benham  "^  succeeded  in  un- 
twisting a  volvulus  which  consisted  of  the  sigmoid  twisted  a 
half-turn  on  itself. 

Bryant  ^  performed  colostomy  in  a  case  which  proved  fatal. 

'  Brit.  Med.  Joiirn.  Epitome,  1893,  vol.  i.  p.  98. 

2  Centralblatt  filr  Chiriirgie,  1894,  vol.  xxi.p.  865. 

'  Brit.  Med.  Journ.  1895,  vol.  i.  p.  979. 

^  Dublin  Journal  of  the  Medical  Sciences,  1893,  vol.  xcv.  p.  97. 

=  Annual  of  the  Universal  Medical  Sciences,  1891,  vol.  iii.  C — 37. 

0  Ibid.  1894,  vol.  iii.  C-26. 

'  Trans.  Clin.  Soc.  Lond.  1895,  vol.  xxviii.  p.  180. 

8  Ibid.  1888,  vol.  xxi.  p.  142. 


(^ALL-STONES    AND   EXTEROLITILS  453 

CHAPTER   LV 

GALL-STONES,    ENTEROLITHS,    FiECAL    ACCUMULATION 

Gall-stones. — It  is  rarely  that  the  presence  of  a  gall-stone 
in  the  large  intestine  gives  rise  to  symptoms  of  any  moment. 
Its  lodgment  for  a  time  in  the  bowel  may  cause  irritation, 
but  it  is  exceptional  for  obstruction  to  result.  A  case,  however, 
is  recorded  by  Korte  '  of  a  woman  aged  72  years,  who  was  sud- 
denly seized  with  symptoms  of  acute  intestinal  obstruction 
the  result  of  a  gall-stone  impacted  in  the  colon.  The  bowel 
was  opened  and  the  stone  removed,  but  the  patient  died. 

Enteroliths. — Intestinal  concretions  or  calculi  have  already 
been  alluded  to  as  occurring  in  the  small  intestine.  They 
are,  however,  more  frequently  met  with  in  the  large,  w^here 
they  may  exist  for  an  indefioite  period  without  giving  rise  to 
symptoms. 

In  structure  and  consistence  they  vary.  In  some  cases 
they  are  hard  and  composed  of  mineral  substances,  chiefly 
phosphatic,  combined  with  animal  matter  and  sometimes 
cholesterine.  In  others  they  are  comparatively  soft  or  porous, 
composed  of  matted  masses  of  vegetable  substances  mixed 
with  faecal  matter,  the  former  consisting  frequently  of  undi- 
gested ligneous  fibres.  A  third  variety  exists,  which  is  formed 
by  the  aggregation  of  substances  which  have  been  taken 
for  medicinal  purposes  ;  such  are  subnitrate  of  bismuth,  car- 
bonate of  magnesia  and  iron  the  result  of  drinking  certain 
chalybeate  waters,  and  chalk. 

Symptoms. — In  the  few  cases  recorded,  the  symptoms  have 
varied.  In  a  case  reported  by  Mentin,^  the  patient  had  been 
a  sufferer  from  intestinal  catarrh,  for  which  she  had  been 
treated  by  the  internal  administration  of  subnitrate  of  bismuth. 
At  the  post  mortem  a  bean-shaped  body  was  found  in  the 
caecum,  composed  of  subnitrate  of  bismuth  85  per  cent,  and  of 
organic  substances  15  per  cent.  There  do  not  appear  to  have 
been  any  symptoms  during  life  suggestive  of  its  presence.  On 
the  other  hand,  in  the  case  narrated  below,  it  will  be  seen  that 
the  symptoms  at  times  were  severe,  and  extended  over  a  period 

'  Berliner  klin.  Wochenschrift,  1893,  p.  690. 

^  Annual  of  the  Universal  Medical  Sciences,  1892  vol.  i.  D— 21 


4o4  THE   LARGE   INTESTINE 

of   several   years.     It   was  possible  in  this  case  to  feel  the 
enterolith  through  the  abdominal  wall. 

Hadden  ^  reports  the  case  of  a  girl  aged  7  years,  who 
suffered  for  several  months  from  chronic  diarrhoea  dependent 
on  intestinal  catarrh.  She  was  treated  during  most  of  this 
time  with  chalk  in  various  forms,  and  with  bismuth.  The 
child  died,  and  at  the  post  mortem  nineteen  distinct  calculi 
were  found  in  the  transverse  colon,  varying  in  bulk  from  the 
size  of  a  large  cherry  to  that  of  an  orange  pip.  Their  chemi- 
cal composition  consisted  of  tricalcium  phosphate,  calcium 
carbonate,  nitrogenous  matter,  and  moisture. 

Case  XCIII. —  Two  enteroliths  in  the  colon,  successfully  removed 
by  colotomy 
A.  woman  aged  50  years  had  suffered  from  periodic  attacks  of  excruci- 
ating pain  about  the  right  ihac  fossa,  recurring  once  or  twice  monthly  and 
accompanied  by  abdominal  distension,  vomiting,  and  constipation.  The 
attacks  had  begun  to  appear  about  twenty  years  before  admission  to  the 
hospital,  and  had  so  increased  as  to  make  her  totally  incapable  of  work. 
Her  bowels  acted  quite  regularly  during  the  free  intervals.  Examination 
of  the  abdomen  revealed  the  presence  of  two  hard,  smooth,  globular 
tumours  situated  one  above  the  other,  somewhat  downward  and  to  the 
right  of  the  umbilicus,  the  upper  being  as  large  as  an  orange,  the  lower 
about  the  size  of  a  hen's  egg.  The  tumours  were  freely  movable  in  the 
vertical  and  lateral  directions,  but  less  so  antero-posteriorly,  the  movement 
causing  great  pain.  The  abdomen  had  gradually  increased  in  size.  The 
bowel  was  opened  by  a  longitudinal  incision  four  inches  long,  and  the 
smaller  mass  removed ;  the  larger  one  required  an  enlargement  of  the 
abdominal  and  intestinal  womids.  The  colon  was  found  considerably 
dilated,  and  its  walls  greatly  hypertrophied.  The  mucous  membrane  was 
thickened,  softened,  purplish,  and  covered  with  numerous  profusely  bleed- 
ing polypoid  excrescences.  The  wounds  were  closed  with  silk  sutures. 
On  the  twenty-first  day  the  patient  left  the  hospital  well.  The  extracted 
bodies  proved  to  be  very  light  enteroliths,  resembling  potatoes  in  their 
shapes,  measuring  six  and  four  and  a  half  centimetres  in  diameter  ;  and 
on  examination  were  found  to  consist  of  fine  ligneous  hairs  or  fibres  of 
some  tree  with  admixture  of  rye — and  oat — barb  scales.  The  belief  was 
that  the  patient  had  been  habitually  eating  bad  bread  made  of  flour  mixed 
with  some  ligneous  substance.  Many  years  ago,  she  had  probably  had  a 
localised  inflammation  of  the  colon  accompanied  by  more  or  less  profuse 
secretion  of  mucus.  Some  masses  of  inspissated  mucus  adhered  to  the 
intestinal  wall,  formed  the  nuclei  around  which  the  insoluble  ligneous 
cells  collected,  and  gradually  formed  the  masses.  (Khalofoff,  reported  by 
J.  Ewing  Mears,  '  Annual  of  the  Universal  Medical  Sciences,'  1891, 
vol.  iii.  C— 40.) 

'  Trans.  Path.  Soc.  Lond.  1888,  vol.  xxix.  p.  131. 


F.ECAL   ACUUMULATIOX  455 

Faecal  accumulation. — The  abnormal  accumulation  of  faeces 
within  the  large  intestine  as  a  whole,  or  in  certain  portions  of 
it,  occasionally  gives  rise  to  symptoms  which  call  for  surgical 
aid.  Bat  for  such  accidents  the  subject  is  one  which  falls 
more  within  the  domain  of  the  physician  than  the  surgeon. 
Only  such  facts  therefore  will  be  introduced  here  as  serve  to 
elucidate  and  explain  those  complications  to  which  such  forms 
of  obstruction  may  give  rise. 

Into  the  various  causes  which  conduce  to  the  accumulation 
of  faeces  in  one  or  other  part  of  the  large  bowel  it  is  not  pro- 
posed to  enter,  nor  will  any  note  be  taken  of  the  enormous 
masses  which  may  so  collect,  and  the  variable  periods  occupied 
in  their  collection.  For  such  details  the  reader  is  referred  to 
an  excellent  resume  of  the  subject  given  by  Treves  in  the 
'  Lancet '  of  1885.i 

No  segment  of  the  large  intestine  is  exempt ;  one  or  more 
may  be  involved  at  the  same  time.  The  csecum,  however,  is 
the  commonest  situation  for  faecal  collections,  and  next  to  it 
the  sigmoid  flexure ;  but  in  some  instances  the  entire  canal 
of  the  caecum,  colon,  and  sigmoid  flexure  become  uniformly 
blocked  and  distended. 

Results  of  faecal  accumulation. — In  the  majority  of  in- 
stances little  more  than  a  sense  of  abdominal  discomfort 
exists,  with  possibly  some  loss  of  appetite  and  general  malaise, 
the  relief  of  which  immediately  follows  upon  a  movement  of 
the  bowels.  The  following,  however,  are  some  of  the  untoward 
symptoms  which  may  arise,  and  suggest  the  advisability  of  a 
surgeon's  opinion,  if  not  also  his  operative  intervention. 

False  tumour. — A  localised  swelling,  or  pseudo-tumour 
formation^  may  in  conjunction  with  other  complications  give 
rise  to  difficulty  in  diagnosis  a,nd  mislead  as  to  the  true  nature 
of  the  case.  In  a  case  reported  by  Worrall,^  a  girl  aged 
13  years  was  observed  to  have  a  rapidly  growing  tumour 
within  the  abdomen.  An  exploratory  laparotomy  was  per- 
formed, when  it  was  foaud  that  the  caecum  and  colon  were 
enormously  distended  with  faeces.  The  operation  had  a  stimu- 
lating effect,  as  after  it  the  bowel  commenced  to  act  and  the 
girl  recovered. 

1  Vol.  ii.  p.  1133.         -  New  York  Medical  Record,  1888,  vol.  xxxiii.  p.  723. 


456  THE   LARGE   INTESTINE 

Not  infrequently  these  fgecal  tumours  possess  character- 
istics sufficiently  distinctive  to  enable  them  to  be  diagnosed 
correctly.  Thus  they  pit  on  pressure,  have  a  dough-like  feel 
to  the  touch,  and  can  be  modified  in  shape  by  squeezing. 
Pressure  usually  causes  no  pain.  In  other  cases  the  tumour 
is  quite  hard  and  unresisting,  conveying  the  sense  of  the 
presence  of  an  intestinal  calculus. 

Pressure. — Symptoms  of  variable  degrees  of  gravity  arise 
as  the  result  of  pressure  of  a  large  accumulation  upon  some 
important  organ.  Middleton  ^  describes  two  cases  where  the 
results  of  pressure  were  seen  upon  the  heart.  In  one  the  apex 
beat  was  displaced  upwards  half  an  inch,  and  inwards,  so  as 
to  lie  nearer  the  sternum  than  usual.  In  the  other  the  area 
of  cardiac  dulness  and  the  apex  beat  were  greatly  displaced 
upwards.  In  this  same  case  there  was  considerable  pressure 
upon  the  bladder,  great  difficulty  was  experienced  in  micturi- 
tion, no  urine  passing  sometimes  for  twenty-four  hours,  and 
ihen  only  in  very  small  quantity.  In  some  cases  of  great  disten- 
sion the  diaphragm  is  pushed  upwards  and  impeded  in  its  action, 
so  that  there  is  considerable  embarrassment  in  respiration. 

JJlceration  and  perforation. — A  serious  complication  of  pro- 
longed fgecal  accumulation  is  ulceration  of  the  bowel.  This 
form  of  ulceration  has  already  been  discussed  under  the 
heading  of  '  Stercoral  ulcer '  (see  page  437).  It  is  only  neces- 
sary to  briefly  refer  to  it  here.  The  process  of  ulceration 
usually  takes  place  slowly,  and  is  frequently  unattended  by 
any  indications  until  perforation  occurs,  when  the  patient 
is  suddenly  seized  with  violent  and  acute  symptoms.  Should 
the  perforation  cause  a  communication  with  the  general 
peritoneal  cavity,  fatal  peritonitis  rapidly  ensues.  In  a  case 
recorded  by  Berry, ^  death  took  place  from  collapse  following 
upon  perforation  of  the  sigmoid  flexure.  The  patient  had 
for  years  suffered  from  chronic  constipation.  At  the  post 
mortem  the  sigmoid  flexure  was  of  such  dimensions  as  to 
reach  the  spleen  and  the  liver,  to  which  it  was  attached  by 
old  adhesions ;  its  inner  surface  presented  shallow  ulcers  and 
perforations.  In  another  case,  recorded  by  Southam,^  death 
took   place    suddenly  from   perforation   of  a  stercoral  ulcer 

'   Glasgow  Med.  Joxirn.  1894,  vol.  xH.  No.  5,  p.  341. 

^  Brit.  Med.  Journ.  1894,  vol.  i.  p.  301.  '  Ibid.  1895,  vol.  i.  p.  254. 


IVECAL   ACCUiMULATION  4o7 

situated  on  the  posterior  wall  of  the  caecum.  The  latter,  with 
the  colon,  was  found  distended  with  hardened  faeces.  The 
patient,  aged  67  years,  had  for  some  months  suffered  from 
incomplete  intestinal  ohstruction. 

In  some  instances  the  stercoral  ulcer  perforates  into  the 
neighhouring  cellular  tissue,  or  contracts  adhesions  to  other 
parts,  so  that  a  localised  faecal  abscess  results,  which  may 
burst  externally  or  empty  itself  into  the  bowel.  Possible 
later  sequels  to  these  ulcers  are  strictures  of  the  bowel. 

Ilwpture. — In  some  few  instances  the  enormous  distension 
of  the  gut  has  led  to  rupture.  The  extraordinary  power  of 
adaptation  which  the  bowel  possesses  under  a  slowly  distend- 
ing force  renders  it  probable,  however,  that  in  most  instances 
the  rupture  results  from  previous  weakening  of  the  intestinal 
wall  through  ulceration. 

Case  XCIV. — Chronic  constipation,  causing  dilatation  and  rui)ture 
of  the  sigmoid  flexure. 
A  man  aged  73  years  had  for  several  years  suffered  from  chronic  con- 
stipation. Three  years  before  his  death  an  attack  of  obstruction  had 
yielded  to  a  smart  purge.  Nine  days  before  admission  to  hospital  he  was 
seized  with  symptoms  of  obstruction,  and  died  from  perforation.  At  the 
post  mortem  the  siginoid  flexure  was  found  enormously  distended,  resem- 
bling in  shape  and  size  an  inverted  and  distended  stomach.  The  inner 
surface  showed  several  ulcers,  and  in  several  places  the  wall  was  gangre- 
nous and  perforated.  The  two  ends  of  the  sigmoid  flexure  were  normal 
in  size  and  position,  and  no  other  part  of  the  intestinal  tract  was  involved. 
(Berry,  '  Trans.  CHn.  Soc.  Lond.'  1894,  vol.  xlv.  p.  84.) 

Although  this  case  is  titled  one  of  rupture,  it  is  question- 
able whether  it  is  not  more  strictly  included  under  the  head 
of  '  Ulceration  and  perforation.'  If,  however,  as  assumed, 
ulceration  is  usually  present,  little  distinction  can  be  drawn 
between  rupture  and  perforation. 

Convulsions. — In  a  case  reported  by  Squires,'  a  child,  11 
months  old,  suffered  from  convulsions  the  result  of  great 
faecal  distension  of  the  bowel.  The  mother  stated  that  the 
child  was  '  terribly  constipated.'  The  result  of  an  enema  was 
to  briug  away  a  great  quantity  of  hardened  scybala,  the  size 
of  hickory  nuts.  The  child  was  immediately  relieved,  and 
after  one  or  two  moreenemata  all  the  symptoms  of  obstruction 
disappeared. 

'  New  York  M&dical  Record  1888,  vol.  xxxi.  p.  241. 


458  THE   LARGE   INTESTINE 

Fcecal  absorption. — The  prolonged  retention  of  fseces  within 
the  bowel  is  liable  to  result  not  only  in  some  changes  in  the 
mucous  lining  of  the  intestine,  but  in  some  chemical  alteration 
of  the  fseces  themselves.  The  combined  result  of  which  it  is 
possible  to  conceive  might  lead  to  the  absorption  into  the 
system  of  products  capable  of  causing  variable  symptoms 
suggestive  of  septic  poisoning.  An  interesting  case  is 
recorded  by  Middleton/  where  it  would  appear  death  resulted 
from  the  absorption  of  ptomaines  or  fsecal  products.  The 
patient's  symptoms  during  life  were  persistent  vomiting, 
high  temperatures  accompanied  with  delirium,  and  parotitis  ; 
enemata  removed  quantities  of  fsecal  material.  At  the  post 
mortem  the  large  intestine  was  found  to  be  full  of  hard  fsecal 
masses.     There  was  no  obstruction. 

Acute  obstruction. — Ileus  paralyticus,  as  this  condition 
of  acute  obstruction  is  sometimes  termed,  is  the  worst  and 
final  phase  of  fsecal  accumulation.  Innocent  as  is  the 
troublesome  condition  of  chronic  constipation  in  the  large 
proportion  of  cases,  instances  are  forthcoming  to  show  that 
the  limits  of  intestinal  forbearance  are  sometimes  reached, 
and  for  some  usually  inexplicable  reason  the  patient  more 
or  less  suddenly  becomes  attacked  with  symptoms  of  acute 
intestinal  obstruction.  In  some  instances,  however,  there 
have  existed  premonitory  indications,  in  the  way  of  greater 
difficulty  than  usual  in  getting  a  movement  of  the  bowels,  the 
trouble  being  accompanied  with  some  loss  of  appetite,  foulness 
of  tongue  and  breath,  nausea,  and  even  vomiting,  symptoms 
which  for  the  time  being  have  cleared  up  immediately  the 
bowels  have  been  opened. 

Why,  after  a  long  period  of  constipation,  symptoms  of 
obstruction  should  suddenly  arise  it  is  not  easy  to  determine. 
Treves  ^  attributes  the  attack  to  one  of  these  causes  :  abrupt 
occlusion  of  the  colon  by  torsion  or  kinking,  peritonitis  set  up 
by  stercoral  ulcers,  and  distension  of  the  small  intestine  due 
to  the  long-tried  ileum  becoming  finally  exhausted  and 
accumulation  taking  place  above  the  ileo-csecal  valve.  It 
may  also  possibly  be  due  to  paralysis  of  the  large  bowel,  which 
finally  refuses  to  react  to  any  further  stimulus,  and  so  causes 

'   Glasgow  Med.  Journ.  1891,  vol.  xli.  Ko.  5,  p.  343. 
2  Lancet,  1885,  vol.  ii.  p.  1133. 


F.ECAL   ACCUMULATION  469 

a  stoppage  as  complete  as  that  effected  by  a  volvulus  or  an 
intussusception.  The  frequency  with  which,  it  is  known,  acute 
symptoms  follow  upon  the  administration  of  a  purge  to 
relieve  a  loaded  colon,  possibly  receives  its  explanation  from 
one  of  the  last  two  causes  given  above.  Faecal  accumulation 
is  sometimes  caused  by  pressure  from  without.  Kidd  '  records 
five  cases  where  it  would  appear  that  a  displaced  kidney  had 
been  the  primary  and  immediate  cause  of  inducing  fgecal 
accumulation  and  obstruction. 

When  once  acute  obstruction  has  set  in,  the  symptoms 
are  practically  indistinguishable  from  those  arising  from  other 
causes  of  obstruction.  The  history  of  years  of  troublesome 
constipation,  with  the  possible  existence  within  the  abdomen 
of  a  tumour,  doughy  to  the  touch,  painless  or  only  slightly 
painful,  and  capable  of  being  moulded  by  pressure— such  are 
the  only  features  which  can  be  said  to  lend  aid  of  any  value 
in  the  formation  of  a  correct  diagnosis.  Even  with  these, 
however,  it  is  sometimes  impossible  to  say  whether  the 
symptoms  may  not  be  due  to  a  tumour  or  to  stricture ;  and 
the  true  nature  of  the  case  does  not  become  manifest  until 
at  the  time  of  the  operation  or  post  mortem. 

Treatment. — Perforation  or  rupture  the  result  of  ulceration 
must  be  treated  on  the  lines  already  laid  down  in  connection 
with  perforation  of  the  bowel  from  other  causes.  What  is  of 
most  interest,  at  present,  is  the  treatment  of  cases  which  are 
suffering  from,  or  show  premonitory  symptoms  of,  intestinal 
obstruction.  It  is  mostly  with  such  that  the  surgeon  is,  as  a 
rule,  concerned  and  where  his  opinion  is  required. 

In  most  instances  treatment  of  some  kind  has  been  adopted 
for  the  chronic  condition  of  constipation  which  has  preceded 
the  acute  attack,  and  has  been  persisted  in  and  increased  as 
preliminary  treatment  of  the  attack  itself.  Hence  it  is  not 
infrequent  to  find  that  the  patient  has  had  powerful  purga- 
tives administered  and  copious  enemata  injected.  The  former 
only  too  often  increase  the  severity  of  the  symptoms,  and  no 
further  trials  of  such  a  kind  should  be  j)ersisted  in.  The 
patient  should  rather  be  kept  from  the  administration  of  any- 
thing by  the  mouth,  food  as  well  as  medicine. 

With  regard  to  fluid  enemata,  either  water  or  oil  may  be 

'  LaiLcct,  1894,  vol.  ii.  p.  lol. 


460  THE   LARGE   INTESTINE 

employed  ;  the  former  is  preferable.  The  object  to  be  attained 
is  percolation  of  the  mass  "with  fluid,  so  that,  being  thus 
loosened  and  softened,  it  may  the  easier  be  dislodged  and 
passed.  The  additional  distension  may  also  serve  as  a 
stimulus  to  peristaltic  action.  The  tube  for  injection  should 
be  inserted  well  up  the  rectum,  if  possible  into  the  commence- 
ment of  the  sigmoid  flexure  ;  it  is  doubtful  whether  it  is  possible 
to  project  it  further  than  this.  "When  the  tube  appears  to 
pass  higher  up,  it  is  more  than  likely  that  it  is  being  doubled 
upon  itself  at  the  upper  part  of  the  rectum.  The  fluid  may 
be  passed  in,  either  by  means  of  an  ordinary  Higginson's 
syringe,  or  allowed  to  gravitate  from  a  funnel  or  filler  held  two 
or  three  feet  above  the  bed. 

Massage  may  prove  of  considerable  service,  but  should  only 
be  employed  at  an  early  stage  of  the  symptoms.  If  a  mass 
can  be  felt  it  should  be  carefully  kneaded ;  and  to  facilitate 
the  action  of  the  hand  and  fingers,  some  lubricant,  such  as  oil 
or  vaseline,  should  be  freely  applied. 

Failing  any  relief  by  such  conservative  measures,  it  becomes 
necessary  to  consider  the  question  of  emptying  the  bowel  by 
operation.  The  operation  best  suited  for  removing  the  con- 
tents of  the  bowel  is  colotomy.  It  has  been  several  times 
practised  with  success.  Pye- Smith  ^  refers  to  a  case,  and 
Cripps  ^  records  an  example,  where,  after  removal  of  an 
impacted  mass  from  the  descending  colon,  he  successfully 
opened  the  csecum  to  relieve  the  distension  which  failed  to  sub- 
side after  opening  the  colon.  A  third  example  is  given  in  the 
case  narrated  below.  A  right  lumbar  colostomy  performed 
in  this  case  was  followed  by  rapid  relief  of  the  symptoms. 

Assuming  that  there  is  no  guide  to  the  portion  of  the 
bowel  most  involved,  an  incision  in  the  left  iliac  region  should 
be  first  made ;  if,  however,  the  sigmoid  flexure  be  found 
undistended,  the  wound  should  be  closed,  and  the  caecum 
explored  by  an  incision  in  the  right  iliac  region. 

Case  XCV. — Acute  intestinal  obstruction  caused  hy  f  cecal  accumulation  : 
colostomy,     llecovery. 
A  man  aged  64  years  had  up  to  seven  months  before  admission  to 
hospital  been  in  good  health,  with,  as  a  rule,  regular  action  of  the  bowels. 

'  Brit.  Med.  Joiirn.  1894,  vol.  i.p.  301.  -  Ibid.  1893,  vol.  i.  p.  398. 


TUMOURS  401 

At  this  period,  however,  he  comaiencecl  to  be  troubled  with  constipation  ; 
and  a  few  months  later  he  suffered  for  several  days  from  '  stoppage  '  of 
the  bowels.  The  attack  was  attended  with  great  abdominal  pain  and 
vomiting,  but  tlie  symptoms  juelded  to  large  injections  of  oil  and  warm 
water.  Another  similar  attack  occurred  three  months  later,  and  while  in 
this  attack  he  was  removed  to  hospital. 

On  admission  he  appeared  in  a  critical  condition,  suffering  much  dis- 
tress. The  bowels  had  not  acted  for  ten  days,  and  the  abdomen  was  very 
tense  and  tympanitic.  A  well-marked  localised  fulness  and  resistance 
existed  over  the  umbilical  region.  This  swelling  was  elastic  and  not 
doughy  in  character.  His  mouth  was  dry,  and  he  vomited  large  quanti- 
ties of  a  dirty  brown  fluid. 

Right  lumbar  colostomy  was  performed.  Large  quantities  of  soft 
fsecal  matter  escaped,  and  relief  to  the  symptoms  immediately  resulted. 
A  few  days  after  the  operation  faeces  began  to  pass  through  the  rectum, 
and  increased  till  the  external  wound  closed  all  but  a  small  fistula,  through 
which  gas  occasionally  escaped.  About  a  month  after  he  left  the  hospital 
he  was  again  seen,  and  was  then  in  very  good  health.  (T,  Ward  Cousins, 
'  Lancet,'  1890,  vol.  i.  p.  80.) 


CHAPTER   LVI 

TUMOURS — INNOCENT    AND    MALIGNANT 

With  the  exception  of  carcinoma,  tumours  involving  the  large 
intestine  resemble  those  met  with  in  the  small.  They  may 
ditfer,  however,  in  their  relative  frequency,  the  large  bowel 
being  more  often  the  seat  of  certain  kinds  than  the  small ;  and 
they  may  differ  also  in  their  clinical  aspects,  more  acute  and 
serious  symptoms  being  liable  to  arise  when  the  tumour  is 
situated  in  the  small  than  in  the  large  intestine. 

Adopting  the  usual  division  of  innocent  and  malignant 
growths,  the  latter  are  more  frequently  met  with  in  clinical 
practice  than  the  former,  though  in  the  post-mortem  room 
innocent  tumours  are  often  discovered  which  have  caused  no 
symptoms  during  life. 

Innocent  tumours. — In  many  instances,  as  aheady  in- 
dicated, these  tumours  are  purely  of  pathological  interest, 
being  frequently  found  in  the  ordinary  course  of  making  a  post 
mortem.  Many  are,  however,  cajDable  during  life  of  causing 
symptoms  of  obstruction,  either  by  reason  of  their  blocking 


462  THE   LARGE    INTESTINE 

the  canal,  or  in  some  other  way  acting  upon  the  bowel  wall 
so  as  to  invaginate,  kink,  or  twist  it. 

Popilloma  and  adenoma. — These  benign  tumours  are  among 
the  commonest  met  with  in  the  large  intestine.  They  vary 
greatly  in  size,  shape,  situation,  and  the  symptoms  to  which 
they  give  rise.  They  are  generally  simple  outgrowths  from 
the  mucous  membrane,  and  resemble  it  in  structure,  being 
either  purely  papillary  excrescences  or  glandular  in  formation. 
In  some  instances  they  are  multiple,  involving  in  such  cases 
not  only  different  parts  of  the  colon,  but  extending  into  the 
rectum  ;  or  rather,  it  should  be  said,  from  the  greater  fre- 
quency with  which  they  are  met  with  in  the  rectum,  they  have 
extended  from  there  into  the  colon.  A  good  illustration  of 
such  multiple  papillomata  is  recorded  by  Dalton.'  The  sym- 
ptoms were  mostly  associated  with  the  papillomatous  mass 
in  the  rectum,  the  patient  suffering  from  pain  in  that  part, 
coupled  with  the  passage  of  blood  and  mucus.  At  the  post 
mortem  isolated  growths  were  found  in  the  sigmoid  flexure 
and  colon,  and  a  considerable  group  in  the  upper  part  of  the 
caecum.     The  patient  was  a  man  aged  '28  years. 

If  instead  of  remaining  sessile  these  tumours  increase  in 
size,  they  become  pedunculated  and  constitute  one  of  the 
commonest  forms  of  intestinal  polypus.  As  such  they  become 
a  not  infrequent  cause  of  intussusception.  In  this  relation 
they  have  already  been  discussed,  the  colic  form  being  fre- 
quently due  to  their  presence.  When  so  associated  the  tumour 
forms  the  apex  of  the  presenting  intussusceptum. 

It  occasionally  happens  that  a  polypus  becomes  spontane- 
ously detached  and  is  passed  per  rectum ;  but,  failing  such  a 
natural  method  of  cure,  these  tumours  may  remain  throughout 
life,  apparently  harmless  and  without  causing  symptoms.  A 
case  recorded  by  Handford,^  however,  would  seem  to  show 
that  it  is  possible  for  these  innocent  growths  to  become  can- 
cerous in  character.  In  the  instance  referred  to,  the  bowel 
from  the  middle  of  the  transverse  colon  to  a  malignant  stric- 
ture in  the  rectum  was  studded  with  polypi,  about  170  in  all, 
most  numerous  in  the  sigmoid  flexure  and  in  the  rectum. 
Some  were  sessile  and  some  pedunculated.     At  one  place  the 

'   Trans.  Path.  Soc.  Lond.  1893,  vol.  xliv.  p.  85. 
2  Ibid.  1890,  vol.  xli.  p.  133. 


INNOCENT   TUMOURS  463 

stages  of  transition  from  a  simple  to  a  malignant  type  could 
be  well  observed. 

Fibroma  and  fihro-myoma. — As  in  the  case  of  the  small 
intestine,  these  tumours  occurring  in  the  large  bowel  constitute 
one  of  the  forms  of  polypus.  They  vary  in  size,  but  are 
usually  small.  Kidd '  showed  a  specimen  at  the  Pathological 
Society  of  London  of  a  fibroma  about  the  size  of  a  pea,  which 
was  attached  to  the  inner  wall  of  the  caecum. 

Lipoma. — Fatty  tumours  are  occasionally  met  with,  either 
growing  within  the  bowel  or  connected  with  it  externally.  In 
the  latter  case  they  are  usually  associated  with  the  appendices 
epiploicEe.  Foulerton^  pictures  an  instance  of  three  fatty 
tumours  in  this  situation  hanging  from  the  transverse  colon. 
They  occurred  in  a  patient  who  died  of  carcinoma. 

Fatty  tumours  arising  within  the  bowel  have  their  origin 
in  the  submucous  tissue.  They  may  grow  to  a  considerable 
size,  and  sometimes  form  pedunculated  tumours  or  polypi. 
HofmokP  reports  a  case  in  which  a  submucous  lipoma  filled 
the  entire  lumen  of  the  intestine  for  several  inches.  It  led 
to  the  ascending  colon  being  invaginated  into  the  transverse. 
In  another  case,  reported  by  Link,'*  the  tumour  was  situated 
in  the  descending  colon  ;  it  was  about  the  size  of  a  man's  fist, 
pedunculated,  and  capable  of  being  felt  externally.  It  was 
successfully  removed.  A  fatty  tumour  combined  with  vascular 
tissue,  under  the  title  of  lipomatous  angioma,  is  described  by 
Williams  ^  as  having  been  found  in  the  descending  colon. 

Dermoids. — These  tumours  are  occasionally  met  with  in 
the  large  intestine.  They  form  usually  pedunculated  growths, 
and  when  situated  in  the  sigmoid  flexure  project  into  the  rec- 
tum, where  they  can  be  felt.  In  a  case  recorded  by  Glutton,^ 
the  tumour,  which  could  be  previously  detected  in  the  rectum, 
was  removed ;  and  when  examined,  it  measured  about  three 
inches  in  its  longest  diameter,  and  weighed  an  ounce  and  a 
quarter.  It  was  covered  externally  with  a  skin,  on  the  surface 
of  which  were  numerous  hairs,  while  inside  it  contained  a 

'  Trans.  Path.  Soc.  Land.  1885,  vol.  xxxvi.  p.  210. 

*  Illustrated  Medical  News,  1889,  vol.  v.  p.  124. 

^  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  iii.  C — 41. 

*  Ibid.  1891,  vol.  i.  D— 19.  *  Ibid.  1895,  vol.  i.  D~-68. 
'  Trans.  Path.  Soc.  Lond.  1886,  vol.  xxxvii.  p.  252. 


464  TliE    LAPtGE   INTESTINE 

small  portion  of  bone,  fat,  and  fibrous  tissue.  Another  case 
is  reported  by  Floyer.^  The  tumour  occurred  in  a  girl  aged 
8  years,  who,  when  at  stool,  suffered  from  tenesmus.  It  pro- 
jected from  the  anus,  was  ligatured  at  its  base  and  removed. 

Cysts. — These  are  little  more  than  pathological  curiosities. 
Sainsbury  ^  exhibited  at  the  Pathological  Society  of  London  a 
tumour  about  the  size  of  a  duck's  egg,  ovoid,  smooth,  and 
elastic.  When  cut  into,  it  proved  to  be  a  cyst  filled  with  very 
dark  ropy  (mucoid)  fluid.  It  was  considered  as  possibly  a 
cjstic  dilatation  of  one  of  the  lips  of  the  ileo-csecal  valve. 

Malignant  tumours. — Of  the  two  primary  forms  of  malig- 
nant growths,  carcinoma  is  frequently  met  with,  while  sarcoma 
but  rarely  occurs.  The  bowel,  when  attacked  by  either  form  of 
disease,  may  be  involved  primarily,  or  growths  may  occur  in  it 
secondarily  to  primary  disease  elsewhere,  or  it  may  become 
implicated  by  direct  extension  from  some  neighbouring  seat. 
When  malignant  disease  of  the  large  intestine  is  spoken  of,  it 
is  always,  however,  taken  to  imply  primary  involvement  of 
that  region,  and  as  such  it  will  alone  be  discussed  here. 

Carcinoma. — The  disease  attacks  both  sexes  in  about  equal 
proportion,  with  slight  tendency,  perhaps,  to  be  commoner 
among  females  than  males.  There  is  no  part  of  the  large 
intestine  exempt,  but  in  by  far  the  larger  number  of  cases  it 
is  either  the  caecum  or  the  sigmoid  flexure  and  the  descending 
colon.  Out  of  fifty  cases  which  I  have  collected,  thirteen 
occurred  in  the  cpecum,  thirteen  in  the  sigmoid  flexure,  and 
eight  in  the  descending  colon  :  and  in  making  an  abstract  of 
Franks's  tables  of  colectomy,^  out  of  thirty-seven  cases,  ten 
occurred  in  the  caecum,  ten  in  the  sigmoid  flexure,  and  nine 
in  the  descending  colon.  The  relative  frequency  with  which 
other  segments  of  the  large  bowel  are  involved  is  best  seen 
by  reference  to  the  accompanying  tables. 

The  disease  is  most  frequently  met  with  after  middle  life, 
but  is  not  uncommon  between  the  ages  of  30  and  40,  and  has 
occurred  in  a  case  reported  by  Powell'*  at  the  early  age  of  23 

'  St.  T]ioinas''s  Hospital  Reports,  1885,  vol.  xv.  p.  239. 

*  Trans.  Path.  Soc.  Lond.  1887,  vol.  xxxviii.  p.  146. 

3  Trans.  Royal  Med.-Chir.  Soc.  1889,  vol.  Ixxii.  p.  211. 

*  Westminster  Hospital  Reports,  1890,  vol.  vi.  p.  94. 


CARCINOMA 


465 


Autliofs  Table  of  Fifty  Cases  of  Carcino'nia  of  the  Large  Intestine, 
shoiuing  situation  of  the  disease 


Ileo-caecal 

v;ilve 

Caecum 

Ascending 
colon 

Hepatic 
flexure 

Transverse 
colon 

Splenic 
flexure 

Descending 
colon 

Sigmoid 
flexure 

6 

13 

4 

1 

3 

2 

8 

13 

Abstract  of  Franlis' s  Table  of  Cases  of  Colectomy,  showing  same  as  above 


Ileo-ceecal 
valve 

Csecum 

Ascending 
colon 

Hepatic 
flexure 

Transverse 
colon 

Splenic 
flexure 

Descending 
colon 

Sigmnid 
flexure 

10 

1 

2 

3 

2 

9 

10 

years,  and  at  22  in  a  case  recorded  by  Sendler,  who  was  suc- 
cessful in  resecting  the  growth. 

Pathology. — Before  attempting  any  description  of  the  form 
or  forms  of  carcinoma  which  attack  the  large  intestine,  it 
will  possibly  simplify  the  discussion  if  it  be  first  stated  what 
classification  constitutes  the  basis  for  reference.  So  many 
terms  are  used  and  in  such  different  senses  that  in  many  in- 
stances it  is  impossible  without  some  such  basis  to  determine 
what  particular  form  is  meant. 

Thus,  then,  I  have  adopted  the  three  primary  divisions  of 
squamous-celled,  columnar-celled,  and  spheroidal-celled  carci- 
noma. The  first  two  constitute  the  epitheliomata,  while  the  last 
embraces  the  medullary  and  scirrhous  forms  of  carcinoma,  both 
of  which  signify  histologically  the  same  structure,  and  only 
differing  in  the  relative  proportion  of  cells  and  intercellular 
fibrous  tissue.  The  former  is  rich  in  cells  and  scanty  in  inter- 
cellular fibrous  trabecule,  while  the  latter  is  scanty  in  cells 
and  possesses  abundant  fibrous  tissue.  All  three  divisions 
are  capable  of  undergoing  a  colloid  change,  when  the  tumour 
constitutes  the  so-called  colloid  carcinoma. 

If  this  classification  can  be  admitted  as  embracing  all 
forms  of  carcinoma,  then  all  difficulty  in  naming  any  particular 
growth  becomes  materially  simplified.  It  requires,  however, 
that  the  growth  be  microscopically  examined  in  order  to 
determine,  in  the  majority  of  instances,  to  which  class  it 
belongs.  Unfortunately,  in  a  large  number  of  the  cases  re- 
corded, terms  are  so  loosely  employed  that  it  is  impossible  to 

H  H 


466  THE    LARGE   INTESTINE 

understand  whether  ttie  name  is  intended  to  have  only  a  vague 
chnical  significance  or  whether  it  is  strictly  histological. 

Judging  from  such  cases  as  have  been  accurately  investi- 
gated, it  would  appear  that  almost  without  exception  the  form 
of  carcinoma  met  with  in  the  large  bowel  is  the  columnar- 
celled  ;  and  wherecolloid  disease  has  been  met  with,  it  is  de- 
generative change  taking  place  in  these  same  cells.  That  this 
form  of  tumour  may  assume  considerable  variations  in  its 
mode  and  rapidity  of  development  is  only  reasonable  to  sup- 
pose from  what  occurs  in  the  case  of  tumours  elsewhere.  This 
variation  has  doubtless  led  to  the  use  of  terms  descriptive 
solely  of  macroscopical  appearances.  Thus  the  commonest 
form  which  is  met  with  when  the  growth  has  developed  to  a 
visible  and  tangible  extent,  is  a  dense  hard  ring  surrounding 
the  gut  at  one  particular  point  (see  Plate  XX,  fig.  58).  It  is 
not  difficult  to  understand  how  this  indurated  consistence  may 
lead  to  it  being  termed  a  scirrhous  tumour,  nor  is  it  any  more 
difficult  to  see  how  any  excessive  growth  causing  a  vascular 
or  sloughing  projecting  mass  into  the  canal  should  be  termed 
a  medullary,  soft,  or  villous  carcinoma. 

Unless,  therefore,  it  can  be  shown  by  a  competent  micro- 
gcopist  that  any  other  form  of  carcinoma  than  the  columnar- 
celled  attacks  the  intestine,  it  would  be  wiser  to  accept 
all  those  cases  that  are  described  as  medullary,  encephaloid, 
scirrhous,  adenoid,  villous,  or  colloid,  as  variations  in  develop- 
ment of  the  one  division  of  columnar-celled  carcinoma. 

Columnar-celled  carcinoma  presents  usually,  in  the  more 
or  less  advanced  stage  of  its  development,  two  separate  ap- 
pearances. In  its  commonest  aspect  it  constitutes  the  so- 
called  ring  stricture  of  the  bowel.  Externally  it  looks  as 
if  the  intestine  had  been  constricted  by  a  string  tied  round 
it.  Internally  the  canal  is  contracted  at  the  same  situation 
by  a  band  of  tissue  which  may  narrow  it  to  any  degree. 
Frequently  there  is  ulceration  at  the  seat  of  stricture,  and  the 
upper  margin  of  the  ulcer  presents  a  typically  everted  and 
indurated  margin  (see  Plate  XXI,  fig.  59).  In  some  cases  the 
stricture  is  of  a  much  more  irregular  character,  the  region  of 
the  disease  being  extensively  ulcerated  and  the  bowel  wall 
considerably  puckered. 

In  its  other  aspect  the  tumour,  in  its  growth   from  the 


PLATE    XX. 


Fig.  58.— Cylinder-celled  Carcinoma  of  Transverse  Colon.— The  growth 
caused  stricture  of  the  bowel.  The  small  aperture  of  continuity  which 
e.xisted  is  indicated  by  a  piece^ofaWhalebone.     {IV. I. M.,  Glas.) 


CARCINOMA  467 

bowel  wall,  projects  as  a  definite  mass  into  the  canal,  tending 
as  it  increases  in  size  to  block  entirely  the  passage.  In  a  case 
recorded  by  Dalton,'  the  carcinoma  formed  a  polypoid  excres- 
cence hanging  from  the  wall  of  the  descending  colon.  Should 
ulceration  attack  the  growth  an  irregular  sloughing  mass 
may  result,  with  the  occasional  detachment  of  portions  which 
are  carried  away,  and  so  temporarily  relieve  the  obstruction. 

The  effect  of  the  growth  within  the  bowel  or  its  walls  is  to 
lead  to  other  pathological  lesions  dependent  upon  the  obstruc- 
tion it  causes,  and  the  progressive  destruction  of  tissue.  The 
result  of  the  obstruction  is  to  cause  dilatation  and  hy^Der- 
trophy  of  the  bowel  immediately  above  the  seat  of  the  disease  ; 
and,  in  consequence  of  the  prolonged  retention  of  the  faeces  in 
the  dilated  part,  the  mucous  membrane  becomes  inflamed  and 
ulcerated,  and  may  at  last  get  so  weakened  that  perforation  or 
rupture  takes  place.  Such  perforation  may  prove  the  incen- 
tive to  a  fatal  peritonitis,  or  result  in  the  formation  of  a  faecal 
abscess. 

As  the  result  of  progressive  destruction  of  tissue,  adhesions 
are  contracted  between  the  involved  part  and  the  neighbour- 
ing tissues.  This  may  be  followed  by  a  direct  invasion  by 
the  tumour,  and  should  destruction  of  tissue  still  proceed, 
communication  may  be  established  between  the  large  bowel 
and  some  other  viscus.  In  a  case  reported  by  Johnson,'^ 
adhesion  took  place  between  the  seat  of  disease  and  the 
ileum,  with  the  result  that  a  fistulous  communication  was 
established  between  these  two  portions  of  the  intestine.  In 
another  case,  reported  by  Joncheres,^  a  communication  was 
opened  up  between  the  stomach  and  the  colon.  And  in  one 
operated  upon  by  Heuston,^  the  bladder  was  opened  into. 

Suppuration  in  connection  with  malignant  disease  of  the 
bowel  is  not  uncommon,  and  probably  owes  its  origin  in  most 
instances  to  the  exposure  of  a  raw  ulcerating  surface  to  septic 
infection  by  the  faecal  contents.  The  effects  of  such  infec- 
-tion  may  show  themselves  locally  at  the  seat  of  the  disease,  or 
more  remotely.     In  the  former  case  abscess  forms  in  direct 

'   Trans.  Path.  Soc.  Lond.  1890,  vol.  xli.  p.  122. 

2  Ibid.  1889,  vol.  xl.  p.  110. 

'  A.nmial  of  the  Universal  Medical  Sciences,  1895,  vol.  i.  D— 57. 

<  Brit.  Med.  Journ.  1894,  vol.  i.  p.  405. 

H   H  2 


468  THE   LARGE   INTESTINE 

connection  with  the  ulcer,  and,  from  its  acute  character,  pro- 
gresses until  it  is  discharged.  In  a  case  reported  by  Money,' 
a  large  post-csecal  abscess  formed  in  connection  with  carcinoma 
of  the  ileo-csecal  valve.  In  the  case  of  abscess  formation  at 
some  more  distant  situation,  the  liver  is  the  part  most  likely 
to  suffer.  Such  cases  become  pysemic  in  character,  and  this 
proves  the  immediate  cause  of  death.  Examples  of  such  a  result 
are  afforded'by  cases  published  by  Dyson  ^  and  by  Finlayson.^ 
In  the  case  of  the  former  the  patient  was  seized  with  rigors, 
and  had  high  temperatures.  (Edema  of  the  right  leg  appeared 
first,  and  then  both  were  involved.  At  the  post  mortem  a 
quantity  of  purulent  matter  and  debris  was  found  in  the 
centre  of  the  growth.  In  Finlayson's  case  high  temperatures 
also  existed,  and  at  the  post  mortem  numerous  small  abscesses 
were  found  located  in  the  liver. 

As  the  stricture  tightens,  or  the  obstruction  increases,  the 
more  solid  and  undigested  constituents  of  the  bowel  contents 
become  retained,  and  hence  it  is  frequently  found  that  the 
dilated  portion  of  the  intestine  above  the  obstruction  is  loaded 
with  foreign  bodies  and  scybalous  masses,  cherry  and  other 
fruit  stones  being  among  the  commonest  examples  of  the 
former.  It  is  usually  some  such  solid  mass  which,  suddenly 
becoming  impacted  or  blocked  in  the  narrowed  channel,  gives 
rise  to  an  attack  of  acute  obstruction. 

Except  in  the  case  of  secondary  gr(/wths  it  is  unusual  for 
carcinoma  to  attack  more  than  one  part  of  the  bowel.  The 
following  two  cases,  however,  seem  to  show  that  multiple  in- 
volvement is  possible.  Symonds  ^  reports  a  case  where,  in  ad- 
dition to  a  malignant  stricture  in  the  sigmoid,  a  second  stric- 
ture was  found  in  the  ascending  colon  which  had  been  the 
means  of  causing  the  death  of  the  patient.  In  the  other  case, 
reported  by  Weichselbaum,^  in  addition  to  numerous  polypi  in 
the  large  and  small  intestine,  three  deposits  of  cancer  were 
found,  one  in  the  caecum,  a  second  in  the  transverse  colon,  and 
a  third  in  the  rectum. 

'  Trans.  Path.  Soc.  Lond.  1889,  vol.  xl.  p.  103. 

2  Lancet,  1884,  vol.  ii.  p.  1005. 

8  Trans.  Path,  and  Clin.  Soc.  Glasgoiv,  1893,  vol.  iii.  p.  145. 

*  Brit.  Med.  Joiirn.  1893,  vol.  i.  p.  638. 

^  Annual  of  the  Universal  Medical  Sciences,  1895,  vol.  i.  D — 57. 


PLATE    XXI. 


Fig-  59-— Carcinoma  of  Colon  producing  ulceration  and  stricture.     {IV.I.m.,  Glas.) 


CARCINOMA  4  CO 

Secondary  growths  arising  from  primary  disease  in  the 
bowel  are  most  frequently  met  with  in  the  mesenteric  glands. 
The  liver  also  is  often  invaded.  In  a  case  recorded  by  Moore,' 
the  rapid  growth  of  a  tumour  in  the  liver  was  a  prominent 
clinical  feature. 

Symptoms. — In  most  cases  there  have  been  symptoms 
dating  back  for  periods  vai'ying  between  a  few  weeks  and 
several  months.  The  patient  has  been  troubled  with  what  has 
been  considered  indigestion  or  biliousness  and  treated  accord- 
ingly. There  may  have  been  diarrhoea,  which  has  sometimes 
alternated  with  constipation,  or  the  latter  has  been  an  in- 
creasingly troublesome  complaint  throughout.  The  diarrhoea 
which  occurs  is  usually  of  a  spurious  kind,  and  is  due  mostly 
to  the  escape  of  the  more  fluid  constituent  of  the  faeces  past 
the  main  mass  of  solid  material  lodged  above  the  seat  of 
obstruction.  The  local  enteritis  setup  by  the  irritative  action 
of  this  hard  faecal  mass  also  tends  to  produce  excretion  of 
mucus,  and  excite  peristaltic  action  of  the  bowel  beyond.  The 
intercurrent  attacks  of  constipation,  or  possibly  its  unbroken 
continuance,  is  produced  by  the  temporary  blocking  of  the 
constricted  or  contracted  canal  by  solid  faeces  which  only  pass 
with  difficulty. 

The  solid  faeces,  when  discharged  per  anuin,  present 
nothing  out  of  the  ordinary  except  when  the  disease  is  situated 
low  down  in  the  sigmoid  flexure,  when  they  occasionally  appear 
flattened  or  ribbon-shaped.  The  presence  of  blood  in  the  faeces, 
or  discharged  independently,  is  occasionally  met  with.  It 
varies  considerably  in  quantity,  being  more  frequently  small 
than  large,  and  is  observed  more  often  when  the  disease  is 
located  in  the  sigmoid  flexure  than  elsewhere.  The  patient 
sometimes  complains  of  tenesmus,  felt  more  particularly  when 
at  stool. 

Pain  is  a  symptom  which  increases  with  the  increase 
in  narrowness  of  the  canal.  It  is  intermittent  and  colicky  in 
character,  depending  more  upon  the  amount  of  obstruction 
than  upon  the  extent  of  the  disease.  Attacks  of  vomiting 
occasionally  occur,  and  what  with  loss  of  appetite,  and  often 
some  nervous  depression,  emaciation  soon  becomes  a  marked 
feature. 

•   Trans.  Path.  Soc.  Land.  1891  vol.  xlii.  p.  172 


470  THE   LARGE   INTEvSTlNE 

Physical  examination  of  the  abdomen  may  or  may  not 
detect  the  existence  of  a  tumour.  When  the  disease  is  in  the 
form  of  a  stricture,  it  is  more  than  likely  to  be  masked  by  the 
distension  of  the  bowel  above.  In  cases  where  there  has  been 
prolonged  chronic  obstruction,  the  abdomen  gradually  becomes 
distended  and  tympanitic.  In  a  case  recorded  by  Courteen/ 
this  distension  assumed  such  unusual  projDortions  that  it  caused 
severe  dyspnoea,  and  the  pressure  upon  the  vena  cava  produced 
oedema  of  the  legs  and  scrotum.  Palpation  of  the  abdomen 
sometimes  induces  a  visible  peristalsis  accompanied  by  colicky 
pains.  Independently,  however,  of  manipulation,  peristalsis  is 
often  seen,  especially  at  those  times  when  the  patient  is  seized 
with  an  attack  of  griping  pain.  Other  sensations  are  often 
complained  of.  The  patient  is  conscious  of  an  action  in  the 
bowels  which  seems  to  work  uj)  to  a  certain  point,  and  end  in  a 
sort  of  gurgle,  indicating  possibly  the  escape  of  gas  through  the 
narrowed  canal. 

A  sudden  complete  block  of  the  canal  calls  forth  a  new 
and  acuter  train  of  symptoms.  The  patient  now  complains  of 
almost  constant  pain  in  the  abdomen.  Distension  becomes 
more  marked  and  peristalsis  more  visible.  Vomiting  becomes 
constant,  and  may  continue  until  it  is  fsecal.  The  pulse  is 
usually  small  and  rapid,  and  becomes  more  markedly  so  as 
time  progresses.  The  temperature  may  be  normal.  The 
patient's  complexion  is  pale  or  sallow,  with  the  typical  abdo- 
minal expression  of  sunken  features,  and  dark  depressions 
below  the  eyes.  The  rectum  when  examined  is  found  empty, 
and  when  fluid  is  injected,  it  returns  practically  unstained 
by  fseces. 

When  in  the  course  of  a  case  of  chronic  obstruction  fever 
symptoms  arise,  these  must  be  taken  to  indicate  either  the 
commencing  formation  of  an  abscess,  or  the  absorjDtion  into 
the  system  of  some  septic  material,  with  possibly  pysemic 
abscess-formation  elsewhere.  In  the  post  mortem  which  I 
made  upon  Finlay son's  case,  already  referred  to,  the  rise  in 
temperature  was  explained  by  the  numerous  minute  pysemic 
abscesses  which  were  found  in  the  liver. 

Another  intercurrent  complication  of  malignant  disease 
of  the  bowel  is  perforation.     This  may  occur  at  any  period  of 

'    Westminster  Hospital  Reports,  1886,  vol.  ii.  p.  204. 


PLATE    XXII. 


Fig.  60.— Colloid  Carcinoma  of  Sigmoid  Flexure.— The  specimen  was  taken 
from  a  child  aged  12  years  which  had  died  of  acute  intestinal  obstruction. 
The  growth  had  caused  stricture  of  the  bowel.     {W.I.M.,  Clas.) 


CAliCINOMA  471 

the  disease,  and  will  be  known,  as  a  rule,  by  the  great  sudden- 
ness with  which  acute  symptoms  set  in.  The  acute  abdominal 
pain,  coupled  with  great  collapse  or  prostration,  will  suggest 
the  nature  of  the  accident. 


CHAPTEE   LVII 

CARCINOMA  (continued),     diagnosis,     prognosis,     treatment 

Diagnosis. — In  most  cases  the  diagnosis  of  malignant 
disease  of  the  large  bowel  must  be  purely  conjectural,  and  based 
rather  upon  probabilities  than  upon  actual  ascertained  facts. 
Gradually  increasing  difficulty  in  defecation  occurring  in  a 
patient  past  middle  life,  accompanied  with  emaciation,  will, 
from  the  simple  consideration  of  probabilities,  indicate,  in  the 
large  majority  of  cases,  carcinoma  of  some  portion  of  the  large 
intestine. 

The  particular  seat  of  the  disease  can  only  occasionally 
be  determined.  When  situated  at  the  ileo-csecal  valve,  it  is 
usual  for  the  symptoms  to  resemble  those  of  disease  of  the 
small  intestine.  There  are,  however,  exceptions,  as  illus- 
trated by  a  case  reported  by  Johnson,^  where  they  were  sug- 
gestive of  chronic  obstruction  of  the  large  intestine.  When 
the  disease  is  situated  in  the  sigmoid  flexure,  -vomiting,  as  a 
rule,  is  less  marked  than  when  the  disease  is  located  higher 
up,  and  more  rarely  becomes  fsecal.  Blood  in  the  motions  is 
more  frequent  with  disease  in  this  part,  and  the  shape  of  the 
solid  motion  is  sometimes  altered,  being  flattened.  The 
most  valuable  aid  to  the  situation  of  the  obstruction  may 
sometimes  be  derived  from  the  injection  of  water  jjer  rectum. 
The  larger  the  quantity  which  can  be  injected,  and  the  longer 
the  time  it  can  be  retained,  the  more  likely  is  the  seat  of 
obstruction  to  be  high  up.  Both  auscultation  and  palpation 
should  be  employed  in  endeavouring  to  determine  the  passage 
of  the  fluid  along  the  colon.  It  needs  to  be  remembered 
that  it  is  possible  for  the  fluid  to  find  its  way  past  the 
obstruction,  and  in  so  doing  to  obscure  the  diagnosis. 

Prognosis. — It  is  usual  for  death  to  occur  in  uncomplicated 

1    Trans.  Path.  Soc.  Loud.  1889,  vol.  xl.  p.  110. 


472  THE   LARGE   INTESTINE 

cases  in  less  than  a  year  from  the  onset  of  the  earliest  sym- 
ptoms. In  many  instances  the  period  would  seem  to  he  much 
shorter,  hut  the  difficulty  of  assigning  the  date  of  the  com- 
mencement of  the  disease  renders  it  impossible  to  fi.x  more 
than  a  comparatively  vague  average.  So  slight  may  be  the 
suffering  in  the  early  stages,  that  the  patient  has  offered  no 
complaint  until  suddenly  seized  with  symptoms  of  acute 
obstruction.  Temporary  relief  occasionally  occurs  and  de- 
ludes the  patient  into  the  belief  that  the  disease  has  dis- 
appeared. The  true  state  of  the  case,  however,  is,  that  the 
channel  has  been  opened  up  by  the  sloughing  away  of  an 
obstructing  mass  of  tumour.  In  other  cases,  again,  relief 
arises  from  the  formation  of  a  faecal  abscess,  which,  bursting 
externally,  allows  of  the  passage  of  faeces  from  time  to  time 
through  the  fistula.  Communications  may  also  be  established 
with  some  other  part,  as  the  bladder  or  another  portion  of 
the  intestinal  tract. 

The  relative  advantages  to  be  gained  by  operation,  and  the 
chances  this  holds  out  for  the  cure  of  the  disease  or  the  pro- 
longation of  life,  will  be  best  discussed  under  the  subject  of 
treatment. 

Case  XCVI. —  Cai-cino'ina  of  the  ascending  colon  causing  chronic 
ohst7'Uction :  colectomy.     Recovery. 

A  woman  aged  36  yearg  began  to  be  attacked  with  pain  in  the  abdomen 
and  flatulence  towards  the  latter  part  of  1893.  The  pain  was  of  a  colicky 
nature,  and  often  very  severe,  and  the  abdomen  was  always  more  dis- 
tended than  it  used  to  be.  In  December,  vomiting  at  intervals  commenced 
and  her  appetite  failed.  "With  the  help  of  medicine  the  bowels  were  fairly 
regalarly  raoved,  but  she  gradually  lost  flesh,  and  becoming  unfit  to 
attend  to  her  household  duties,  finally  took  to  bed.  When  first  seen  in 
consultation,  she  was  in  a  weak  state  of  health,  with  colicky  pains,  abdo- 
minal distension,  and  vomiting.  The  bowels  were  only  moved  with  great 
difficulty,  and  the  motions  contained  mucus  and  sometimes  blood.  The 
seat  of  the  disease  could  not  be  located,  but  was  thought  to  be  high  up,  as 
large  enemata  could  be  retained. 

Operation. — A  median  exploratory  incision  was  made,  and  a  tmnour 
discovered,  in  the  ascending  colon.  This  incision  was  closed,  and  a  second 
made  over  the  position  of  the  growth.  Immediately  the  abdomen  was 
opened,  the  caecum,  greatly  distended,  bulged  into  the  wound  and  inter- 
fered with  the  progress  of  the  operation,  so  it  was  incised  and  a  quantity 
of  gas  and  fluid  faeces  allowed  to  escape.  When  the  bowel  had  emptied 
itself,  the  opening  was  clamped,  and  the  mesenteric  vessels  leading  to  the 
affected  portion  of  bowel  were  ligatured,  the  mesentery  divided,  and  the 


CARCINOMA  473 

loose  loop  of  gut  brought  out  of  the  abdominal  cavity.  About  five  inches 
of  bowel  were  now  excised,  and  glass  intestinal  drainage  tubes  were  tied 
into  each  end.  Finally  the  wound  in  the  mesentery  was  drawn  together 
with  green  catgut,  and  the  two  ends  of  the  bowel  were  attached  side  by 
side.  On  the  seventh  day  the  upper  tube  was  removed,  and  the  lower  on 
the  tenth.  On  the  fourteenth  day  a  pair  of  long  dressing  forceps  were  tied 
in  with  the  object  of  removing  the  spur.  This  being  accomplished  to  a 
sufficient  depth,  the  rosette  of  mucous  membrane  showing  on  the  surface 
was  separated  from  the  skin  and  sutured  together,  and  the  skin  closed 
over  it.  Primary  union  occurred,  and  henceforth  the  bowels  were  moved 
by  the  natural  passage.  (F.  T,  Paul,  '  Brit.  Med.  Joum.'  1895,  vol.  i. 
p.  1138.) 

Case  XCVII. — Carcinoma  at  the  junction  of  the  ccecum  and  ascending 

colon  causing  acute  ohstruction :  colostomy  :  intestinal  anastomosis. 

Death  three  months  after  from  exhaustion. 

W.  S.,  aged  27  years,  was  admitted  into  the  Bristol  General  Hospital 
on  October  15,  1894,  with  the  following  history.  For  five  months  he  had 
been  subject,  every  few  weeks,  to  attacks  of  pain  in  the  right  iliac  fossa, 
lasting  a  few  hours,  and  accompanied  by  the  presence  of  a  round,  firm 
swelling  the  size  of  a  hen's  egg,  which  appeared  midway  between  the 
anterior  superior  spine  and  the  umbilicus,  and  always  disappeared  as  the 
pain  ceased.  A  fortnight  before  admission  general  abdominal  pain  set  in. 
The  bowels  acted  for  the  first  week,  but  there  had  been  complete  obstruc- 
tion (no  flatus  having  been  passed)  during  the  last.  On  admission  he  was 
very  much  emaciated.  The  abdomen  was  considerably  and  uniformly  dis- 
tended, and  every  few  minutes  distended  coils  became  visible,  and  a  very 
hard  swelling  formed  in  the  right  iliac  fossa  which  felt  like  a  solid  mass, 
but  it  subsided  with  the  cessation  of  the  peristalsis.  No  satisfactory 
action  of  the  bowels  could  be  obtained  by  enemata. 

02:)eration. — An  exploratory  median  incision  was  made  and  a  distended 
caecum  and  a  collapsed  sigmoid  flexure  discovered.  This  incision  was  then 
closed,  and  a  second  made  over  the  caecum,  when  a  constricting  mass  of 
new  growth  was  found  at  the  junction  of  the  caecum  and  ascending  colon, 
binding  the  bowel  down  inseparably  to  the  iliac  fossa.  The  caecum  was 
stitched  to  the  abdominal  wall  and  opened.  About  three  months  later  a 
second  operation  was  performed,  which  consisted  in  forming  an  ana- 
stomosis between  the  small  intestine  and  the  sigmoid  flexure.  This  was 
successfully  effected  by  means  of  Murphy's  button.  The  patient  lived  for 
three  months,  and  then  died  from  gradual  exhaustion  due  to  the  increased 
growth  of  the  tumour.  (Charles  A.  Morton,  '  Brit.  Med.  Journ.'  1895, 
vol.  i.  p.  859,  and  vol.  ii.  p.  962.) 

Treatment. — If  the  same  reasoning  is  to  be  applied  to  car- 
cinoma of  the  bowel  as  is  considered  proper  in  the  case  of 
carcinoma  elsewhere,  then  so  soon  as  the  disease  is  diagnosed 
or  even  only  suspected  it  should  be  dealt  with,  without  further 
delay,  by  surgical  measures.     There  is  everything  to  hope  for 


474  THE   LARGE    INTESTINE 

in  early  treatment,  while  with  delay  the  situation  becomes 
aggravated.  To  attempt  to  remove  the  disease  at  an  early 
period  is  to  do  so  when  it  is  most  limited,  and  when  the 
patient  is  best  fitted  to  endure  the  operation.  But  any  such 
endeavour  at  a  late  stage  may  not  only  be  inadvisable,  but 
possibly  prohibited,  and  nothing  but  palliative  measures  can 
then  be  employed. 

Statistics  cannot  be  said  to  prove  much  at  any  time,  and 
possibly  in  connection  with  the  treatment  of  carcinoma  of  the 
large  intestine  they  are,  for  many  reasons,  specially  of  little 
value.  The  publication  of  individual  successful  cases  is 
encouraging,  but  cannot  be  said  to  establish  a  particular 
course  of  general  application.  Taken,  however,  for  whatever 
they  may  be  worth,  the  following  statistics  are  not  without 
interest. 

In  1889  Franks  '  published  a  table  of  fifty-one  cases  of 
colectomy  performed  between  the  years  1843  and  1888.  Of 
these,  twenty  died  as  the  result  of  the  operation  within  thirteen 
days,  giving  a  mortality  of  40-8  per  cent.  In  only  one  case 
does  there  appear  to  have  been  what  was  considered  a  cure  ; 
in  this  instance  four  inches  of  colon  were  removed,  and  no 
recurrence  was  observed  at  the  end  of  four  years. 

In  1895  Mayo  Kobson  ^  reported  thirteen  cases  of  colectomy 
operated  on  in  the  Leeds  Infirmary  during  the  past  two  years. 
The  record  shows  a  mortality  of  23  per  cent. 

Such  evidence  as  the  above  seems  to  show,  therefore,  that 
the  various  modern  improvements  in  intestinal  operations  have 
materially  lessened  the  rate  of  mortality  following  thereupon  ; 
and  as  each  year  adds  an  increasing  number  of  successful 
cases,  it  may  be  reasonably  hoped  that  the  operation  of  colec- 
tomy will  soon  occupy  an  established  position  among  the 
methods  of  treating  this  disease. 

If  the  disease  can  be  located  by  external  examination,  a 
sufficient  guide  exists  for  the  line  of  incision,  which  should  be 
carried  through  the  parietes  over  the  affected  area ;  if  no 
such  evidence  can  be  obtained,  an  exploratory  incision  should 
be  made  in  the  median  line,  and  the  situation  and  extent  of 


'   Trans.  Royal  Med.-Ghir.  Soc.  Loncl.  1889,  vol.  Ixxii.  p.  211. 
■  Brit.  Med.  Journ.  1895,  vol.  ii.  p.  965. 


CAKCIXOMA  476 

the  disease  ascertained.     The  median  incision  is  then  closed, 
and  a  second  made  over  the  affected  area. 

Assuming  that  excision  is  the  proper  course  to  adopt  where 
the  tumour  or  stricture  is  free  and  non-adherent  and  the 
patient's  condition  good,  the  question  then  to  decide  is  the 
kind  of  operation  to  perform.  Should  excision  be  immediately 
followed  by  end-to- end  or  lateral  anastomosis  and  the  bowel 
returned  into  the  abdomen  ;  or  should  both  ends  of  the  divided 
intestine  not  be  united,  but  secured  outside  the  abdomen,  and 
the  continuity  of  the  canal  established  at  a  later  period  ?  Or, 
thirdly,  should  the  tumour  with  the  involved  bowel  be  with- 
drawn from  the  abdomen,  an  artificial  anus  made,  and  the 
growth  subsequently  removed  ? 

Each  of  these  three  methods  can  claim  success,  but  the 
last  two  are  apparently  the  safer.  As  an  example  of  the  first 
method,  a  case  recorded  by  Lilienthal  ^  may  be  given.  Four 
inches  of  the  transverse  colon  were  removed  for  carcinomatous 
stricture  of  the  part ;  end-to-end  anastomosis  was  effected  by 
a  large  Murphy's  button.  A  wedge  of  meso-colon  and  that 
part  of  the  omentum  which  adhered  to  the  new  growth  were 
also  removed,  and  with  it  the  entire  distal  omentum.  The 
patient  made  a  good  recovery,  gaining  both  in  weight  and 
strength.  The  button  was  passed  on  the  eighteenth  day  with- 
out jDain.  The  second  method  is  advocated  by  Paul,"-^  who,  in 
a  very  fair  and  impartial  discussion  of  the  question  based  on 
practical  experience,  advises  that  immediate  end-to-end  ana- 
stomosis by  Murphy's  button  should  only  be  attempted  '  when 
the  patient  is  in  good  condition,  the  abdomen  not  distended, 
the  tumour  small,  and  the  proximal  end  of  the  bowel  not 
greatly  hypertrophied  ; '  and,  I  should  venture  to  add,  the  ends 
of  the  divided  bowel  capable  of  being  approximated  without 
tension.  Such,  however,  is  usually  likely  to  be  the  case  when 
the  tumour  is  small.  Under  the  opposite  conditions  Paul 
advocates  the  bringing  of  the  ends  of  the  bowel  out  of  the 
wound  and  securing  them  there  with  glass  drainage  tubes 
inserted  into  both.  For  details  of  the  method  of  operating 
see  Operations  upon  the  Intestines. 

There  is  but  little  difference  between  the  second  and  third 

'   Netu  Yo7-k  Med.  Journ.  1894,  vol.  Ix.  p.  264. 
-'  Brit.  Med.  "Journ.  1895,  vol.  i.  p.  1136. 


476  THE   LARGE   INTESTINE 

methods  of  operating.  The  delay,  ho'\;veTer,  in  removing  the 
growth  lessens  somewhat  the  magnitude  and  immediate 
danger  of  the  operation.  AUingham/  in  a  case  of  successful 
excision  hy  this  latter  method,  pulled  the  growth  with  about 
fifteen  inches  of  the  gut  through  the  inguinal  incision  and 
secured  it  outside  the  abdomen.  An  artificial  anus  was  made, 
and  ten  days  later  the  tumour  was  removed. 

When  the  disease  is  more  extensive  and  more  of  the  bowel 
is  involved  than  will  admit  of  the  case  bemg  considered  suit- 
able for  excision  by  any  one  of  the  three  methods  above  de- 
scribed, other  measures  have  to  be  carried  out. 

Eeverdin  ^  reports  a  successful  case  of  removal  of  the 
transverse  colon  for  a  cylindrical  epithelioma  which  involved 
the  intestine  for  nine  inches.  The  distal  end  of  the  colon  was 
invaginated  and  sutured,  while  the  proximal  end  formed  an 
artificial  anus  just  above  the  umbilicus.  The  patient  four 
months  afterward  had  gamed  considerably  in  weight. 

When  excision  is  impossible,  or  from  secondary  growths 
elsewhere  inadvisable,  either  a  colostomy  should  be  performed, 
which  of  all  palliative  measures  may  be  considered  the  safest, 
or  the  ileum  should  be  emplanted  mto  the  colon  below  the 
seat  of  disease ;  in  other  words,  an  ileo-colostomy  performed. 
In  cases  where  the  disease  involves  the  csecum  so  that  it  is 
impossible  to  open  the  large  bowel  on  the  proximal  side, 
ileostomy  must  be  performed.  Briddon  ^  reports  having  suc- 
cessfuUy  accomplished  this  in  a  case  where  the  disease  was  so 
extensive  as  to  implicate  the  whole  length  of  the  large  intes- 
tine. 

Should  operation  be  refused  by  the  patient,  or  for  any 
other  reason  be  deemed  mad^dsable,  an  endeavour  must  be 
made  to  relieve  the  bowels  either  by  the  administration  of 
suitable  aperients  or  the  use  of  fluid  enemata. 

Sarcoma. — The  rarity  of  this  kmd  of  tumour  affecting 
the  large  bowel  as  a  primary  disease,  renders  it  unnecessary 
to  more  than  briefly  allude  to  it.  It  is  said  to  attack  the 
bowel  usually  in  the  form  of  the  spindle-celled  variety.  I  have 
only  come  across  the  record  of  two  cases  within  recent  years. 

'   Trans.  Clin.  Soc.  Lond.  1893,  vol.  xxvi.  p.  140. 

^  American  Journal  of  the  Medical  Sciences,  1893,  N.S.  vol.  cv.  p.  588. 

'  Annals  of  Surgery,  1894,  vol.  xx.  p.  414. 


PLATE    XXIII. 


Fig.  6i.— Round-celled  Sarcoma  of  Large  Intestine.— The  tumour  caused  no 
symptoms  during  life.  Similar  masses  and  nodules  were  found  in  the 
cerebellum  and  in  the  right  lung.     (W.I.M.,  Gins.) 


IDIOPATHIC   DILATATION  477 

Hofmold '  reports  having  successfully  excised  the  caecum, 
peart  of  the  ascending  colon,  and  the  appendix  for  an  adeno- 
sarcoma  ;  and  Abbe  ^  removed  a  large  mass  affecting  the  same 
regions  of  the  bowel  from  a  boy  aged  6  years,  who  died  thirty- 
six  hours  after  the  operation  from  shock.  No  microscopic 
description  of  the  tumour  is  given,  so  that  some  doubt  must 
attach  to  the  true  character  of  the  growth. 

Lymphadenoma,  although  more  frequent  in  its  involvement 
of  the  stomach  and  small  intestine,  sometimes  attacks  the 
large  bowel,  as  instanced  by  cases  collected  and  recorded  by 
Pitt.=* 


CHAPTEE   LVIII 

IDIOPATHIC    DILATATION.       ABNORMALITIES  :    MISPLACEMENTS    AND 
MALDEVELOPMENT 

Idiopathic  dilatation  of  the  colon. — Intimately  associated 
with  faecal  accumulation,  if  not  often  dependent  upon  it,  is  so- 
called  idiopathic  dilatation  of  the  colon.  Numerous  cases  are 
on  record,  both  of  young  and  old,  where  from  no  known  cause 
segments  of  the  large  intestine  have  become  enormously  dis- 
tended and  led  to  symptoms  which  have  simulated  those 
of  obstruction  and  suggested  operative  intervention  for  their 
relief. 

As  already  indicated,  it  is  possible  that  in  some  of  these 
cases  of  great  distension  the  colon  has  suffered  as  the  result 
of  chronic  constipation.  In  others,  again,  it  is  possible 
that  some  slight  kinking  or  twisting  has  caused  temporary 
or  partial  obstruction,  with  consequent  gradual  distension. 
There  are  cases,  however,  in  which  the  enlargement  appears 
to  be  unquestionably  congenital,  and  it  is  more  particularly 
with  these  that  the  term  '  idiopathic  dilatation  '  has  come 
to  be  associated.  In  the  remarkable  instance  recorded  by 
Walker,"*   the    enlargement   of    the   abdomen  was   noticed    a 

'  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  iii.  B  — 31. 
^  Annals  of  Surgery,  1895,  vol.  xxi  p.  592. 
3  Trans.  Path.  Soc.  Loncl.  1889,  vol.  xl.  p.  80. 
*  Brit.  Med.  Journ.  1893,  vol.  ii.  p.  230. 


478 


THE    LARGE   INTESTINE 


few  weeks  after  birth,  and  it  continued  to  increase  until  the 


child   died    of    emaciation 


and  exhaustion  at  the  age  of 
11  years.  At  the  post  mortem 
the  transverse  and  descending 
colon  measured  twenty-three 
inches  round,  '  looking  like  a 
la.rge  leg  and  thigh.'  The  com- 
mencement of  the  csecum  and 
the  distal  end  of  the  sigmoid 
flexure  were  normal.  A  still 
more  remarkable  case  appears 
to  be  that  reported  and  figured 
by  Formad'  (see  fig.  62).  The 
patient,  aged  29  years,  had  so 
large  an  abdomen  that  he  was 
exhibited  under  the  name  of  the 
'balloon  man.'  He  died  sud- 
denly from  syncope,  the  result, 
it  was  supposed,  of  pressure  on, 
or  displacement  of,  the  heart. 
The  colon  was  as  large  as  that 
of  an  ox.  His  chief  symptom 
during  life  was  constipation.  In 
another  case,  reported  by  Hirsch- 


^=-'        sprung,^    death   occurred    early 


Fig.  62. — Enokmous  Congenital 


-the    child    only   reached    the 
_     _     __     age  of  2  months.     At  the  post 

Development  oe  Colon.    (Formad)    niortem     the     transverse      Colon 

Front  view,  showing  dii^tension  of  abdomen,  ^^g  fouud  enormously  enlarged, 
reaching  as  far  down  as  the  umbilicus.  A  somewhat  similar 
instance  of  early  death  is  reported  by  Oestreich.^  The  child 
lived  for  a  year  and  a  half. 

Osier*  discusses  the  subject  from  the  congenital  aspect, 
and  narrates  the  histories  of  three  cases  occurring  in  young 
children.  In  one,  a  boy  aged  3  years,  death  resulted  from 
an  attack  of  acute  colitis.     At  the  post  mortem  the  colon  was 

•  Annual  of  the  Universal  Medical  Sciences,  1893,  vol.  i.  D     28. 

2  lUd.  1892,  vol.  i.  D— 28. 

3  Berliner  klin.  Wochenschrift,  1893,  p.  852. 
••  Archives  of  Pediatrics,  1893,  vol.  x.  p.  111. 


IDIOPATHIC    DILATATION  479 

enormously  dilated,  holding  fourteen  pints  of  water ;  the  greatest 
dilatation  was  in  the  neighbourhood  of  the  siguioid  flexure. 
He  had  been  troubled  with  constipation  since  birth.  In  the 
second  case  the  boy  was  aged  10  years  when  first  seen,  and 
complained  of  a  swollen  and  painful  abdomen.  His  symptoms 
subsequently  took  the  form  of  frequent  attacks  of  pain  and 
vomiting.  For  the  relief  of  these  laparotomy  was  performed, 
when  it  was  found  that  the  sigmoid  flexure  was  the  portion 
most  distended.  An  artificial  anus  was  made  in  this  part,  and 
the  symptoms  all  subsided.  In  the  third  case  the  child  was 
aged  7  months  when  first  seen.  At  the  outset  it  was  noticed 
that  its  napkins  were  not  soiled.  The  abdomen  became 
swollen  and  tender.  Belief  had  to  be  obtained  by  injections. 
Unless  these  were  given  daily,  the  belly  would  swell  and  the 
child  vomit. 

As  illustrations  of  dilatation  existing  at  a  comparatively 
late  period  of  life,  the  following  cases  may  be  referred  to. 
Heriingham  ^  records  the  case  of  a  man,  aged  78  years,  who 
had  suffered  all  his  life  from  constipation.  Eleven  days  before 
death  he  failed  to  obtain  any  action  of  his  bowels.  His  sym- 
ptoms grew  worse  and  the  abdomen  was  opened,  when  it  was 
found  that  perforation  had  taken  place.  At  the  post  mortem 
the  disease  was  found  to  consist  in  enormous  dilatation  of  the 
sigmoid  flexure ;  the  intestine  above  and  below  was  natural. 
Another  very  similar  case  is  reported  by  Money.-  In  this 
instance  the  man  was  aged  55  years,  and  suffered  from  extreme 
dyspnoea,  blueness  of  lips,  nose,  ears,  and  nail-beds,  and 
general  duskiness  of  the  "tace  and  skin.  At  the  post  mortem 
the  sigmoid  flexure  was  found  most  markedly  affected,  and 
two  large  sacs  existed,  each  far  bigger  than  an  ordinary 
dilated  stomach.  Several  other  cases  are  referred  to  by  this 
author. 

In  most  of  these  cases  the  bowel,  in  addition  to  being 
greatly  dilated,  is  also  considerably  hypertrophied ;  so  that 
associating  this  state  of  the  bowel  wall  with  the  frequent  con- 
genital origin  of  the  disease,  it  would  seem  reasonable  to  sup- 
pose that  the  condition  was  rather  one  of  abnormal  develop- 
ment of  the  part  than  the  result  of  acquired   pathological 

1  Brit.  Med.  Journ.  1894,  vol.  ii.  p.  1240. 

-  Tra72S.  Clin.  Soc.  Loud.  1888,  vol.  xxi.  p.  103. 


480  THE   LARGE   INTESTINE 

changes.  It  would,  however,  involve  too  extensive  a  discussion 
of  the  subject  to  pursue  further  the  possible  causes  of  this 
form  of  dilatation.  It  is  of  special  interest  to  the  surgeon 
purely  from  the  clinical  aspect. 

Treatment. — From  the  cases  recorded,  it  would  appear  that 
the  best  form  of  treatment  to  adopt  in  all  but  extreme  in- 
stances is  the  regular  use  of  water  enemata,  employed  daily 
or  at  such  periods  as  required  ;  in  some  few  cases  aperients 
have  answered.  As  long  as  relief  can  thus  be  obtained  and 
no  more  serious  symptoms  develop,  anything  in  the  way  of 
operation  should  be  avoided.  If,  however,  the  distension 
interferes  with  the  proper  action  of  the  heart,  or  impedes 
respiration,  the  most  distended  portion  of  the  gut  should  be 
opened,  its  contents  removed,  and  a  faecal  fistula  established. 

Case  XCVIII. — Congenital  dilatation  of  the  colon.     Death. 

A  boy  aged  12  years  had  been  subject  to  constipation  since  6  months 
of  ao-e.  On  admission  to  St.  George's  Hospital  he  was  emaciated.  The 
eyes  were  sunken  and  the  complexion  of  a  bistre  tint.  The  abdomen 
was  enormously  distended,  and  the  peristaltic  contractions  of  the  intestine 
could  be  seen.  During  the  three  months  that  he  was  under  observation 
his  condition  varied,  often  very  suddenly.  He  would  improve  for  a  time, 
the  bowel  acting  daily  and  the  abdomen  becoming  soft.  Then  suddenly 
constipation  and  vomiting  would  come  on  without  manifest  cause.  The 
attacks  usually  subsided  in  a  day  or  two,  but  in  one  of  them  he  died. 
There  was  never  any  obstruction.  The  treatment  was  varied,  but  with 
the  exception  of  calomel,  nothing  seemed  to  do  any  material  good. 

Post  mortem. — Great  dilatation  of  the  colon  was  found.  No  stricture 
or  cause  for  obstruction  could  be  found  anywhere.  There  were  numerous 
ulcers  in  the  colon,  due  presumably  to  distension  ;  the  muscular  coats 
were  hypertrophied.  (H.  D.  Eolleston  and  Warrington  Haward,  '  Brit. 
Med.  Journ.'  1896,  vol.  i.  p.  1326.) 

Abnormalities. — The  enormous  increase  within  recent  years 
of  exploratory  operations  upon  the  abdomen,  not  to  speak  of 
the  performance  of  operations  for  definite  purposes  and  more 
especially  for  intestinal  obstruction,  renders  it  imperative  that 
the  surgeon  should  be  familiar  with  some  of  the  more  commonly 
met  with  misplacements  and  malformations  of  the  large  intes- 
tnie.  The  additional  fact  also  that  intestinal  defects  may  of 
themselves  give  rise  to  symptoms  resembling  other  affections, 
renders  a  knowledge  of  them  still  more  important.  Just  to 
briefly  illustrate  what  has  been  said,  and  to  indicate  the  prac- 
tical difficulties  which  the  surgeon  may  have  to  encounter, 


MISPLACEMENTS  481 

Lockwood '  narrates  two  cases  where  an  endeavour  was  made 
to  open  the  colon  for  obstruction,  but  in  neither  could  the 
bowel  be  found.  It  was  subsequently  ascertained  that  the 
failure  was  due  to  an  absence  of  the  colon  from  its  normal 
position. 

For  practical  purposes  it  is  possible  to  divide  the  abnor- 
malities of  the  large  bowel  into  misplacements  and  those  due 
to  maldevelopment.  It  is  probable  that  similar  causes  give 
rise  to  both.  Intra-uterine  inflammation,  and  deficiency  in 
the  processes  of  normal  development  may  conduce  on  the 
one  hand  to  the  bowel  not  occupying  its  proper  position, 
and  on  the  other  to  a  congenital  malformation  of  the  part. 
The  existence  of  adhesions  in  any  particular  case  would  sug- 
gest the  possibility  of  some  fcetal  inflammation  as  a  cause. 

Misplacements. — 1.  Of  the  whole  bowel. — Cases  occasionally 
occur  of  transposition  of  the  viscera,  by  which  is  understood 
the  occupation  of  the  left  side  of  the  body  by  organs  normally 
situated  on  the  right,  and  vice  versa.  Such  conditions  give  rise 
to  no  symptoms,  and  as  a  rule  are  discovered  somewhat  acci- 
dentally. It  is  not  difficult,  however,  to  conceive  the  trouble 
which  might  arise  should  for  any  cause  operation  upon  the 
large  bowel  be  necessary.  In  a  case  recorded  by  Cheadle,^ 
the  heart  was  found  to  be  situated  on  the  right  side ;  and 
this  discovery  led  to  the  diagnosis  of  complete  transposition 
of  the  stomach,  liver,  and  spleen,  from  which  it  v/as  inferred 
that  the  caecum  must  be  in  the  left  iliac  fossa  and  the  sigmoid 
flexure  in  the  right. 

One  of  the  most  serious  displacements  of  more  or  less  of 
the  large  bowel  is  its  passage  through  a  congenital  aperture 
in  the  diaphragm  into  the  cavity  of  the  thorax.  In  a  less 
marked  degree  this  constitutes  a  form  of  diaphragmatic 
hernia.  In  an  extraordinary  case  reported  by  Eustace  Smith, ^ 
the  whole  of  the  colon  from  the  csecum  to  the  middle  of  the 
sigmoid  had  passed  into  the  chest  through  a  congenital  aper- 
ture in  the  left  ligamentum  arcuatum  externum.  The  c^cum 
remained  in  the  abdomen  just  below  the  diaphragm.  The 
rounded  opening  was  about  an  inch  in  diameter.     The  case 

'   St.  Bartholmneiv's  Hospital  Reports,  1883,  vol.  xix.  p.  255. 

=  Lancet,  1892,  vol.  i.  p.  803. 

'  Archives  of  Pediatrics,  1887,  vol.  iv.  p.  385. 

I  I 


482  THE   LAEGE    INTESTINE 

was  that  of  an  infant  which,  when  first  seen,  suffered  from 
intensely  violent  attacks  of  pain  and  dyspnoea.  When  these 
passed  off  the  child  was  left  pale  and  exhausted.  In  one  of 
these  attacks  it  died. 

A  peculiar  course  taken  by  the  large  bowel  is  reported  by 
Tirard.^  The  condition  had  not  apparently  given  rise  to 
symptoms  during  life,  but  the  child  died  at  the  age  of  3|  years 
from  cardiac  disease.  At  the  post  mortem  the  caecum  was 
found  attached  by  a  distinct  omentum  to  the  edge  of  the  fissure 
for  the  gall  bladder,  the  bladder  itself  lying  between  the  two 
layers.  From  the  caecum  the  large  intestine  ran  in  an  oblique 
direction  to  the  left  iliac  fossa,  where  it  made  a  sharp  bend  to 
the  right,  and  passed  below  the  coils  of  the  small  intestine  to 
the  right  iliac  fossa,  from  which  point,  after  making  a  gentle 
curve,  it  descended  on  the  right  side  of  the  pelvis  to  the 
anus. 

2.  Of  the  c(ecum. — The  position  of  the  caecum  is  liable  to 
considerable  variation.  Lockwood,^  after  describing  a  case 
where  it  was  situated  opposite  the  crest  of  the  right  ilium, 
discusses,  from  a  developmental  point  of  view,  the  various 
situations  in  which,  from  any  defect  in  this  process,  the  caecum 
is  liable  to  be  arrested.  Thus  it  may  be  located  on  the  left  side 
of  the  abdomen  ;  or  be  free  in  the  peritoneal  cavity,  being 
held  in  position  by  a  mesentery ;  or  it  may  be  retained  close 
to  the  cardiac  end  of  the  stomach,  or  in  the  right  hypochon- 
drium ;  or,  lastly,  any  way  between  this  and  the  iliac  fossa. 
Numerous  examples  are  given  in  illustration  of  each  of  these 
abnormal  situations.  A  case  is  recorded  by  Fowler  ^  where 
the  caecum  was  found  immediately  behind  the  liver.  The 
patient  was  operated  upon  for  appendicitis.  Upon  opening 
the  abdomen  and  exploring  its  cavity  the  caecum  could  not  be 
found  in  the  right  iliac  fossa,  but  the  transverse  colon  was 
found  to  descend  to  the  level  of  the  pubes,  a  portion  of  it 
occupying  the  usual  site  of  the  ascending  colon.  On  tracing 
this  it  led  upwards  to  the  caecum,  behind  the  liver. 

3.  Of  the  sigmoid  flexure. — One  of  the  commonest  dis- 
placements of  the  sigmoid  flexure  is  into  the  right  iliac  fossa, 
the  bowel  continuing  into  the  rectum  on  the  right  side. 

1  Lancet,  1892,  vol.  i.  p.  1131.  ^  Brit.  Med.  Journ.  1882,  vol.  ii.  p.  575. 

*  Annals  of  Snrgery,  1894,  vol.  xix.  p.  160. 


M  A  LI)]-:  VE  LOPM  ENT  4H3 

In  reaching  this  position  it  is  usual  for  the  descending 
colon  to  take  an  oblique  course  across  the  abdomen,  opposite 
the  third,  fourth,  or  fifth  lumbar  vertebra.  In  this  form  of 
displacement  the  ctecum  is  apt  to  be  displaced  from  its  normal 
situation,  and  the  left  iliac  fossa  usually  becomes  occupied 
by  the  small  intestine.  In  a  case  reported  by  Dexter  '  of  an 
adult  male  subject,  the  descending  colon  was  found  to  pass 
from  the  splenic  flexure  across  the  abdomen,  opposite  the 
third  lumbar  vertebra,  to  the  right  iliac  fossa.  The  caecum, 
ascending  and  transverse  colons  were  in  their  normal  positions, 
while  the  small  intestine  alone  occupied  the  left  iliac  fossa. 

Other  rarer  and  more  remarkable  variations  in  the  mis- 
placements of  the  sigmoid  are  described  by  Melsome  ^  in  the 
'  Proceedings  '  of  the  Anatomical  Society  of  Great  Britain  and 
Ireland.  Four  examples  are  recorded.  In  three  of  these 
the  variation  was  largely  due  to  the  greater  size  and  length 
of  the  omega-loop. 

That  undue  increase  in  the  length  and  size  of  the  sigmoid 
may  give  rise  to  symptoms  is  shown  by  a  case  recorded  by 
Holt.^  The  child  suffered  from  recurrent  attacks  of  tympan- 
ites, which  lasted  sometimes  for  a  week.  At  the  post  mortem 
the  sigmoid  portion  of  the  colon  was  elongated  and  reflected 
upwards  so  as  to  cover  the  abdominal  viscera  almost  com- 
pletely. 

Maldevelopment. — Included  under  this  division  is  a  class 
of  cases  which  has  already  been  discussed  under  the  head  of 
'Idiopathic  dilatation  of  the  coIod.'  Many  of  these  cases,  it 
was  shown,  were  probably  congenital  in  their  origin,  and 
possibly  due  to  some  developmental  defect. 

Another  class  of  cases  exists,  in  which  the  bowel  suffers 
from  some  abnormality  in  shape  or  structure.  In  this  class 
are  included  pouches,  sacculi,  and  diverticula.  In  a  case 
recorded  by  Hamilton,*  where  the  patient  died  from  chronic 
phthisis,  numerous  diverticula  were  found  in  the  sigmoid 
Hexure  like  those  commonly  met  with  in  the  bladder.  They 
consisted  of  a  protrusion  of  the  mucous  membrane  through 

'  Boston  Med.  and  Surg.  Journ.  1893,  vol.  exxix.  p.  479. 

"  Journal  of  Anatomy  and  Physiology,  1892-93,  vol.  xxvii.  p.  xxx. 

•■'  Neio  York  Med.  Journ.  1886,  vol.  xliii.  p.  225. 

■•  Neio  York  Medical  Record,  1888,  vol.  xxxiii.  p.  721. 

I  I  2 


484  THE    LARGE    INTESTINE 

the  muscular  coat.  In  another  case,  reported  by  Hale  White/ 
the  descending  colon,  sigmoid  flexure,  and  first  part  of  the 
rectum  conta'ned  a  number  of  diverticula,  mostly  circular  or 
oval,  about  a  third  of  an  inch  in  diameter,  and  transverse 
to  the  long  axis  of  the  bowel.  Tbey  varied  in  depth,  the 
longest  being  half  an  inch  deep.  There  was  no  indication  of 
disease.  In  a  quite  exceptional  and  remarkable  case  described 
and  depicted  by  Fiitterer,^  a  congenital  diverticulum  of  the 
sigmoid  flexure  formed  an  enormous  globe-shaped  projection 
from  the  bowel  wall. 

Of  a  somewhat  different  character  is  a  case  recorded  by. 
Lockwood.^  A  man  aged  57  years  died  of  intestinal  obstruc- 
tion. At  the  post  mortem  the  caecum  was  found  in  the  right 
hypochondriac  region,  beneath  the  liver.  The  colon  coursed 
from  the  caecum  to  the  splenic  flexure,  and  thence  descended 
into  the  pelvis.  The  descending  colon  was  double  ;  both  tubes 
were  upon  the  same  plane,  the  smaller  one  nearer  the  ver- 
tebral column  :  it  contained  no  faeces.  Each  possessed  appen- 
dices epiploicae. 

Deficiency  in  development  is  sometimes  met  with  where, 
as  in  other  parts  of  the  intestinal  tract,  the  bowel  termi- 
nates in  a  cul-de-sac.  Such  malformations  constitute  one  of 
the  causes  of  obstruction  met  with  in  the  new-born,  where 
neither  gas  nor  faeces  pass  per  rectum.  In  a  case  recorded 
by  Anderson,*  the  child  passed  its  meconium  through  the 
umbilicus.  It  lived  twenty-three  days,  and  after  death  it 
was  discovered  that  the  large  intestine,  which  was  otherwise 
normal,  terminated  at  the  crest  of  the  left  ilium  in  a  conical 
blind  extremity. 

In  another  class  of  cases  the  bowel,  instead  of  ending 
blindly,  communicates  by  a  fistulous  opening  with  the  bladder 
or  urethra.  Hurd^  records  the  case  of  a  child  which  lived 
for  fifteen  months  passing  its  faeces  jjer  urethram.  At  the  post 
mortem  the  intestinal  canal  was  found  normal  except  at  its 
lower  part,  where  there  was  an  entire  absence  of  the  rectum. 

'  Trans.  Path.  Soc.  Lond.  1885,  vol.  xxxvi.  p.  215. 

^  Archiv  filr  Path.  Anat.  1886,  vol.  cvi.  p.  555. 

^  Brit.  Med.  Journ.  1882,  vol.  ii.  p.  574. 

*  Trans.  Path.  Soc.  Lond.  1891,  vol.  xlii.  p.  128. 

^  Boston  Med.  and  S^irg.  Journ.  1885,  vol.  exiii.  p.  294. 


ABNOUMALITIES   OF   THE   ILEO-C.ECAL    VALVE       48o 

The  descending  colon,  with  its  sigmoid  flexure  dilated  pnd 
distended,  was  forced  over  to  the  right  side,  where  it  opened 
by  a  narrow  rigid  tube,  an  inch  and  a  half  in  length  by  half 
an  inch  in  diameter,  into  the  prostatic  portion  of  the  urethra, 
just  behind  the  pubic  arch.  Boyd  ^  records  a  somewhat 
similar  case,  only  the  communication  was  between  the  sigmoid 
and  the  bladder.  Gas  and  meconium  were  similarly  passed 
by  the  urethra. 

Possibly  one  of  the  rarest  defects  in  development  is  recorded 
by  Dodd.^  A  male  infant  lived  for  twelve  weeks,  suffering, 
on  and  off,  from  vomiting,  constipation,  and  pain.  At  the 
post  mortem  it  was  found  that  the  ascending  and  transverse 
colon  were  throughout  but  little  larger  than  an  ordinary  lead 
pencil.     The  head  of  the  caecum  was  normal. 

Abnormalities  of  the  ileo-csecal  valve. —  The  only  feature 
worthy  of  notice  in  connection  with  any  abnormality^  of  the 
ileo-csecal  valve  is  some  lack  of  development,  either  partial  or 
complete,  in  its  two  folds.  The  condition  possibly  exists  more 
frequently  than  recorded  examples  would  imply.  There  are 
no  symptoms  known  to  result  from  such  a  defect,  and  its 
discovery  has  only  been  made  during  life  from  the  fact  that 
enemata  given  per  rectum  have  been  found  to  produce  a  taste 
in  the  mouth  of  some  ingredient  contained  within  the  injec- 
tion, or  that  they  have  actually  been  ejected  by  the  mouth. 
Birmingham  ^  exhibited  a  specimen  at  the  Eoyal  Academy 
of  Medicine  in  Ireland,  where  a  mere  rudiment  of  one  of 
the  flaps  was  present;  and  in  the  Hunterian  Museum  of 
the  University  of  Glasgow  a  preparation  exists  which  was 
obtained  from  a  young  lad  who  died  of  peritonitis.  Clysters 
thrown  up  the  rectum  were  in  a  few  minutes  vomited,  the 
linseed  oil  appearing  on  the  surface  of  the  vomit.* 

'  Edinburgh  Med.  Journ.  1889,  vol.  i.  p.  529. 

^  Lancet,  1892,  vol.  i.  p.  1299. 

'  Brit.  Med.  Journ.  1893,  vol.  i.  p.  241. 

*  Museum  Catalogue,  p.  87a;  also  Brit.  Med.  Journ.  1892,  vol.  ii.  p.  1199. 


486  THE   INTESTINES 

CHAPTER   LIX 

EMBOLISM    AND    THROMBOSIS    OF    THE    MESENTERIC    VESSELS  ' 

It  may  not  at  first  sight  appear  what  interest  any  obstruction 
to  the  flow  of  blood  in  the  mesenteric  vessels  can  have  for 
surgeons.  Immediately,  however,  one  grasps  the  fact  that  to 
cut  off  the  arterial  blood  supply  to  a  segment  of  the  bowel  is 
to  paralyse  that  particular  portion,  it  becomes  at  once  evident 
that  a  patient  whose  mesenteric  artery  becomes  suddenly 
blocked  will  be  seized  with  acute  obstruction. 

The  effect  which  a  complete  stoppage  of  the  circulation  has 
upon  the  bowel  is  best  understood  by  comparing  it  with  the 
more  familiar  and  precisely  similar  conditions  resulting  from 
the  strangulation  of  a  loop  of  intestine  beneath  a  band  or 
through  a  hernial  aperture.  The  sequence  of  pathological 
events  which  takes  place  in  the  latter  instance  has  already 
been  sufficiently  described  to  need  any  further  recognition  here. 
The  bowel  will  almost  certainly  become  gangrenous,  and  ■  per- 
foration cause  a  fatal  peritonitis.  The  condition  therefore  is 
a  grave  one,  and  calls  for  treatment  without  delay. 

Embolism  or  thrombosis  of  the  mesenteric  vessels  occurs 
mostly  in  late  life,  and  is  almost  without  exception,  in  the  case 
of  the  arteries,  associated  with  disease  of  the  cardiac  valves 
or  with  atheromatous  disease  of  the  aorta.  The  mesenteric 
vessels  may  be  involved  either  at  their  origin,  or  more  re- 
motely in  some  of  their  smaller  branches. 

Symptoms. — Adenot,^  who  records  a  case  of  thrombosis  of 
the  inferior  mesenteric  artery  producing  gangrene  of  the  colon, 
discusses  the  subject  at  some  length.  He  quotes  Kussmaul, 
who  gives  the  following  symptoms  as  those  most  frequently 
met  with  :  a  marked  and  sudden  fall  of  temperature  ;  violent 
abdominal  pains  of  a  colicky  character  ;  distension  of  the 
abdomen  with  tympanites ;  intra-abdominal  effusion,  and 
copious  excessively  fetid  stools.     He  further  indicates  that  it 

'  I  am  indebted  to  Dr.  Rutherfurd  for  drawing  my  attention  to  a  valuable 
paper  by  John  Moyesin  the  Glasgoiu  Medical  Journal  for  1880,  vol.  xiv.  p.  485,  on 
'  Embolism  of  the  Superior  Mesenteric  Artery.'  A  good  bibliography  is  appended. 

■■^  Rcvicc  de  Midecine,  1890,  vol.  x.  p.  267. 


EMBOLISM    &   THROMBOSIS   OF   MESENTERIC  VESSELS    487 

is  possible  by  the  character  and  continuous  flow  of  blood 
passed  per  rectum  to  determine  which  of  the  two  mesenteric 
vessels  is  involved.  If  the  blood  is  decomposed  the  embolus 
is  situated  in  the  superior  mesenteric  ;  if  on  the  other  hand 
it  is  fresh  the  inferior  mesenteric  is  involved.  Again,  the 
situation  of  the  pain  is  considered  of  assistance.  Thus  when 
an  itching  and  burning  pain  is  complained  of  about  the  anus, 
it  is  the  inferior  mesenteric ;  when  the  pain  approaches  the 
region  of  the  umbilicus  it  is  the  superior. 

Of  these  symptoms  the  passage  of  blood  and  the  rapid  fall 
in  the  temperature  are  the  most  significant.  The  quantity  of 
blood  passed  depends,  however,  upon  the  magnitude  of  the 
vessels  obstructed.  In  a  case  recorded  by  M'Carthy,^  no  blood 
was  passed  ;  but  in  this  instance  it  was  not  the  trunk  of  the 
artery  which  was  involved  but  its  arterioles  ;  emboli  were  dis- 
covered in  several  termmal  branches  of  the  superior  mesenteric. 
The  case  was  that  of  a  man  aged  77  years,  who  was  admitted 
into  hospital  for  symptoms  resembling  those  of  acute  intestinal 
obstruction.  He  was  seized  with  severe  pains  in  the  right 
hypogastric  region,  vomiting  set  in  and  lasted  for  six  days, 
during  which  time  there  was  no  action  of  the  bowels,  and 
neither  flatus,  blood,  nor  mucus  was  discharged  per  anum. 
He  had  the  typical  abdominal  face  and  a  feeble  pulse.  The 
abdomen  was  neither  tender  nor  tense ;  distended  coils  of 
intestine  could  be  seen ;  there  was  dulness  in  both  flanks. 
Laparotomj^  was  performed,  and  a  perforation  discovered  in 
an  intensely  congested  and  livid  coil  of  ileum  about  twelve 
inches  from  the  ileo-csecal  valve.  The  mesentery,  which  was 
loaded  with  fat,  was  slightly  ecchymosed,  and  the  blood  vessels 
leading  to  the  collapsed  and  congested  bowel  were  filled  with 
clot.  The  aorta  was  found  at  the  post  mortem  to  be  very 
atheromatous. 

The  blood  exuded  may  not  find  its  way  into  the  bowel,  but 
may  form  collections  in  the  bowel  wall  or  in  the  mesentery, 
and  should  this  take  place  to  any  extent  it  may  lead  to  the 
possibility  of  a  tumour  being  felt  through  the  parietes.  Such 
was  the  case  in  the  patient  whose  report  is  given  in  detail 
below. 

Thrombosis  of  tlie  superior  mesenteric  vein. — The  following 

'  Lancet,  1890,  vol.  i.  p.  646. 


488    EMBOLISM   &   THROMBOSIS   OF   MESENTERIC  VESSELS 

interesting  case  is  the  only  one  I  have  met  with  illustrative  of 
involvement  of  the  mesenteric  vein  and  not  the  artery.  The 
case  is  described  by  McWeeny,'  and  as  it  adds  another  to 
those  numerous  causes  of  sudden  abdominal  pain  ending  in 
rapid  collapse  and  death  it  is  worthy  of  note.  The  patient 
was  a  girl  who  after  recovering  from  an  attack  of  erysipelas 
was  suddenly  seized  with  violent  pains  in  her  stomach,  became 
collapsed,  and  died  in  the  course  of  a  few  hours.  At  the  post 
mortem  great  dilatation  of  the  tributaries  of  the  superior 
mesenteric  vein  was  found,  with  intense  congestion  of  the 
portion  of  the  bowel  from  which  the  veins  sprung  ;  this  was  in 
a  state  of  hsemorrhagic  infarction,  and  there  seemed  to  have 
been  a  weeping  hgemorrhage  into  the  bowel,  for  it  contained 
about  a  quart  of  blood. 

Case  XCIX. — Embolism  of  the  inferior  mesenteric  artery,  with  symptoms 
of  obstruction :  laparotomy.     Death. 

A  man  aged  51  years,  while  lifting  a  heavy  bar  of  metal,  felt  a  peculiar 
sensation  in  the  lower  part  of  his  abdomen.  This  was  followed  by  pain 
and  a  feeling  of  weakness,  which  necessitated  his  leaving  his  work.  On 
the  same  evening  he  passed  from  a  pint  to  a  pint  and  a  half  of  blood  by 
the  bowel,  and  the  following  morning  he  again  passed  about  half  a  pint. 
He  was  away  from  work  for  a  week,  during  which  time  he  experienced, 
more  or  less  constantly,  colicky  pains  in  the  abdomen,  and  suifered  from 
constipation,  necessitating  his  taking  a  purgative.  He  returned  to  work, 
but  only  for  four  or  five  days,  the  general  weakness  and  abdominal  pain 
compelling  him  to  give  up.  Frora  this  period  up  to  his  admission  into 
hospital  he  had  had  no  movement,  and  purgatives  administered  had  had 
no  effect.  He  had  been  vomiting  more  or  less  the  whole  time,  and 
colicky  pain;  variable  in  severity,  had  been  a  constant  source  of  trouble. 

On  admission  three  weeks  after  he  was  first  seized,  he  looked  some- 
what pale  and  exhausted  ;  the  tongue  was  foul  and  the  temperature  sub- 
normal, and  it  remained  so,  gradually  falling,  up  to  the  time  of  his  death. 
The  abdomen  on  inspection  was  found  to  be  markedly  distended.  In  the 
left  iliac  fossa  a  hard  mass  about  the  size  of  a  large  orange  could  be 
felt. 

Two  days  after  admission  laparotomy  was  performed.  The  mass  in 
the  iliac  fossa  was  due  to  a  large  decolorised  infarction  in  the  mesentery 
of  the  sigmoid  flexure.  There  were  two  infarcts  also  in  the  mesentery  of 
the  small  bowel.  The  ascending,  transverse,  and  descending  colons  were 
enormously  distended  and  very  dark  in  colour ;  the  walls  appeared  to  be 
thinned  by  the  distension  to  which  they  had  been  subjected,  and  theyhad 
a  doughy  feel  to  the  touch.     The  small  intestines  were  red  and  deeply 

'  Dublin  Journal  of  the  Medical  Sciences,  1894,  vol.  xcvii.  p.  169. 


THE   YEKMIFOIIM    APPENDIX— ANATOMY  4S9 

injected,  which,  together  with  the  more  recent  appearances  of  the  infarcts, 
proves  that  the  inferior  mesenteric  artery  was  first  affected.  The  patient 
sank  about  twenty  hours  after  the  operation.  No  post  mortem  was  allowed. 
(Munro,  '  Lancet,'  1894,  vol.  i.  p.  147.) 


CHAPTEE   LX 

THE    VERMIFORM    APPENDIX.       ANATOMY.       APPENDICITIS 

The  vermiform  appendix  represents  a  portion  of  the  in- 
testinal canal  which,  at  an  early  period  of  foetal  life,  was  a 
continuation  of,  and  differed  little  from,  the  colon.  At  a  later 
period  of  intra-uterine  life  its  development  ceased,  and  it  then 
became  merely  an  appendage  of  the  caecum,  with  an  inherent 
tendency  to  retrogress  and  degenerate. 

As  met  with  at  birth  and  throughout  the  rest  of  life,  it 
appears  as  a  wormlike  organ,  variable  in  its  shape,  size,  and 
situation,  and  connected  with  the  caecum  usually  on  its  inner 
and  posterior  surface,  close  below  the  entrance  of  the  ileum. 

Eibbert,^  in  his  investigation  upon  the  appendix,  points  out 
that  retrogression  manifests  itself  as  age  advances  in  three 
ways  :  reduction  in  length,  alterations  in  histological  structure, 
and  obliteration  of  the  canal.  In  early  life  it  possesses  a 
canal  continuous  with  that  of  the  caecum,  but.  in  later  years 
this  connection  is  sometimes  cut  off,  and  in  many  cases  partial 
or  complete  occlusion  takes  place.  Between  the  tenth  and 
thirtieth  year  Eibbert  found  that  14  per  cent,  of  the  cases 
examined  presented  partial  occlusion,  and  between  the  sixtieth 
and  eightieth  year  as  many  as  55*5  per  cent.  According  to 
Struthers,^  '  about  ^  inch  may  be  given  as  a  fair  average 
diameter  taken  at  the  middle.  .  .  .  The  diameter  usually 
diminishes  a  httle  distally,  but  not  always ;  the  end  is 
usually  blunt-pointed,  sometimes  quite  blmit,  sometimes,  but 
not  often,  sharp-pointed.'  In  length  the  appendix  varies  from 
an  inch  to  nine  and  a  half  inches,  its  average  length  being 
about  three  and  a  half  inches.  In  thickness  it  is  about  equal 
to  a  goose  quill. 

'   Virchow's  Archiv,  1893,  Bel.  cxxxii.  p.  66. 

2  Edinburgh  Med.  Journ.  1893,  vol.  xxxix.  part  i.  p.  290. 


490  THE   VEEMIFORM   APPENDIX 

Attached  to  one  border,  for  a  variable  extent,  is  its  mesen- 
tery, which  usually  connects  it  with  the  ileum  or  is  continuous 
with  its  mesentery.  In  the  mesentery  are  contained  the  blood 
vessels,  lymphatics,  and  nerves.  The  appendicular  artery  is 
derived  from  the  ileo-colic  branch  of  the  superior  mesenteric. 
It  passes  usually  along  the  free  border  of  the  meso-appendix, 
giving  off  branches  in  its  course.  The  nerves  are  derived 
from  the  superior  mesenteric  plexus,  a  derivative  of  the  solar 
plexus. 

In  shape  the  appendix  presents  considerable  variation, 
being  straight,  curved,  bent,  or  twisted  like  a  corkscrew.  These 
variations  may  in  some  cases  be  due  to  the  shortness  of  the 
meso-appendix,  in  others  to  the  undue  length  of  the  appendix. 

Of  most  practical  interest  to  the  surgeon  is  the  situation 
of  the  appendix.  This  particular  part  of  the  anatomy  of  the 
organ  has  been  exhaustively  considered  by  J.  D.  Bryant  ^  in  a 
valuable  contribution  on  the  '  Eelations  of  the  Gross  Anatomy 
of  the  Vermiform  Appendix  to  some  Features  of  the  Clinical 
History  of  Appendicitis.'  The  observations  are  based  upon 
the  examination  of  144  cases.  Giving  only  five  out  of  the 
fourteen  different  situations  recorded,  the  appendix  was  found 
directed  upwards  in  thirty-four  cases,  behind  the  caecum  in 
thirty-two,  downwards  and  inwards  in  twenty-eight,  into  the 
true  pelvis  in  twenty-one,  and  upwards  and  inwards  in  nine ; 
thus  leaving  only  twenty  cases  to  be  allocated  among  the 
remaining  nine  situations.  In  three  only  of  these  144  cases 
was  the  appendix  situated  extra-peritoneally — that  is  to  say, 
it  lay  behind  in  the  retrocsecal  or  post-peritoneal  connective 
tissue. 

In  structure  the  appendix  resembles  the  other  parts  of  the 
intestine  in  possessing  four  coats,  but  differs  somewhat  in  its 
minute  anatomy.  In  most  instances  the  peritoneum  covers 
the  organ  completely;  when  it  does  not  do  so,  the  uncovered 
part  is  connected  with  the  post-peritoneal  connective  tissue. 
The  muscular  coat  is  somewhat  irregular  in  its  distribution. 
Longitudinal  fibres  are  found  forming  a  uniformly  disposed 
external  sheath  ;  deeper  is  an  internal  and  thicker  coat  of 
unstriped  circularly  placed  fibres  combined  with  fibrous  tissue. 
Between  the  muscular  and  mucous  coats  is  a  layer  of  connective 

'  Annals  of  Surgery,  1893,  vol.  xvii.  p.  164. 


APPENDICITIS  491 

tissue  constituting  the  submucous  tunic.  Lastly,  a  mucous 
membrane  forms  the  lining  of  the  canal.  In  this  latter  are  a 
number  of  solitary  lymph  follicles.  The  abundance  of  lymphoid 
tissue  in  the  raucous  membrane,  especially  at  an  early  period 
of  life,  has  led  to  a  comparison  between  this  part  and  the 
tonsils,  and  also  suggested  a  possible  source  of  inflammation 
in  the  organ. 

In  early  and  middle  life  the  appendicular  canal  usually 
communicates  by  an  aperture  with  the  cavity  of  the  csecum, 
the  mucous  lining  of  the  two  parts  being  continuous.  The 
presence  of  anything  like  a  fold  constituting  a  valve  to  the 
orifice  of  the  canal  is  disputed. 

Mucus  is  secreted  by  the  lining  membrane,  and  constitutes 
one  of  the  products  contained  within  the  canal.  It  is  interest- 
ing in  connection  with  the  question  of  contents  of  the  canal 
to  refer  to  Bryant's  paper.'  Out  of  124  autopsies  made  for 
other  reasons  than  disease  of  the  appendix,  67  per  cent,  con- 
tained abnormal  material ;  fsecal  matter,  either  soft  or  hard, 
was  present  more  frequently  than  anything  else,  being  noted  in 
52  per  cent,  of  the  male  and  in  35  per  cent,  of  the  female 
cases.  In  no  instances  were  there  other  than  fsecal  substances, 
or  products  dependent  on  inflammation,  present  in  these 
cases.  Grape  seeds,  cherry  stones,  and  bodies  foreign  to 
the  intestine  were  not  found  at  all.  As  regards  the  relation 
of  age  to  contents,  from  30  years  to  50  is  the  period  of  life 
in  which  material  of  some  kind  is  most  frequently  found. 

Inflammatory  affections  of  the  appendix. — Appendicitis. — 
Ten  years  or  so  ago,  a  few  lines  would  have  sufficed  to  say 
all  that  was  supposed  of  any  special  interest  to  the  surgeon 
regarding  the  inflammatory  affection  of  the  vermiform 
appendix.  Now,  however,  it  is  difficult  to  know  how  to  con- 
dense within  the  reasonable  space  of  a  few  pages  what  every 
surgeon  should  know,  so  rapid  and  extensive  has  been  the 
advance  made  in  this  particular  subject. 

By  appendicitis  is  to  be  understood  an  inflammation  of 
the  appendix  vermiformis  ;  the  initial  lesion  may  not  be  in- 
flammatory, but  inflammation  arises  sooner  or  later. 

Much  has  been  written  in  recent  years  on  the  subject, 
so  much  indeed  that  not  a  little  confusion  has  been  caused  by 

'  Annals  of  Surgery,  1893,  vol.  xvii.  p.  172. 


492  THE    VEKMIFORM   APPENDIX 

the  various  discussions  over  the  classification  of  the  different 
lesions  met  with,  the  causes  of  such  lesions,  and  the  proper 
treatment  to  adopt.  This  has  largely  arisen  on  the  one 
hand  from  the  extensively  varied  natural  course  which 
the  disease  may  run,  coupled  with  the  equally  varied  and 
numerous  complications  which  may  at  any  time  arise ;  and 
on  the  other  hand  from  a  too  hasty  endeavour  on  the  part  of 
writers  to  formulate  opinions,  and  promulgate  advice  based 
upon  a  too  limited  experience. 

To  the  Americans,  and  more  particularly  to  Fitz  and 
McBurney,  belong  the  credit  of  first  indicating  the  true  clini- 
cal significance  of  inflammatory  affections  of  the  appendix. 
Pathologists  had  long  taught  the  frequency  with  which  the 
organ  was  found  diseased,  but  it  is  only  within  comparatively 
recent  years  that  light  has  been  thrown  upon  the  symptoms 
to  which  it  gives  rise  and  the  possibility  of  successful  treat- 
ment demonstrated.  Pathologists  knew  of  the  diseased  organ  : 
chnicians  knew  of  an  inflammation  frequently  located  in  the 
right  iliac  fossa,  but  it  has  been  left  to  comparatively  modern 
investigation  to  demonstrate  the  connection  between  the  two ; 
that  the  one  is  the  cause  and  the  other  the  effect. 

No  contribution  to  the  subject  in  recent  years,  I  venture 
to  think,  can  compare  with,  or  claim  higher  commendation 
than  that  of  the  American  surgeon  George  E.  Fowler,^  who, 
on  the  basis  of  no  fewer  than  169  personally  observed  cases, 
has  carefully  searched  into,  tabulated,  and  reasoned  out  facts 
which  constitute  the  most  reliable  foundation  for  any  discus- 
sion of  the  subject.  I  must  personally  acknowledge  the  value 
this  contribution  has  been  to  me  in  endeavouring  to  present  a 
clear  and  concise  review  of  the  disease.  In  common  with  most 
surgeons,  several  cases  have  come  under  my  own  observation  ; 
l)ut  I  should  fall  into  the  very  error  which  I  have  already  con- 
demned if  I  made  these  the  basis  of  generalisations,  apart 
from  the  large  groups  of  recorded  cases,  such  as  have  been 
presented  by  this  distinguished  surgeon. 

Pathology. — The  classification  of  inflammatory  diseases 
of  the  appendix  has  constituted  one  of  the  difficult  questions 
connected  with  the  subject,  and  its  difficulty  largely  arises 

'  Annals  of  Surgery,  1894.  vol.  xix.  pp.  4,  146,  327,  475,  546. 


APPENDICITIS-PATIIOI^OG  Y  493 

from  the  fact  that  what  has  sometimes  been  described  as  one 
form  of  the  disease  has  been  merely  a  stage  in  the  process  of 
another.  If  such  conditions  are  excepted  as  arise  from 
some  sudden  obstruction,  mechanical  or  pathological,  to  the 
arterial  supply  of  the  organ,  all  other  conditions  may  be  said 
to  be  stages  in  the  progress  of  some  initial  inflammation  set 
up  by  an  exciting  cause  most  probably  located  within  the 
appendicular  canal.  Thus  a  slight  general  inflammation  of 
the  mucous  membrane  would  constitute  a  catarrh  or  endo- 
appendicitis ;  should  this  extend  into  the  jDarietes  it  would 
constitute  an  interstitial  inflammation  ;  further  progress 
would  involve  the  peritoneum  and  produce  a  peri- appendicitis 
which  may  end  in  remaining  a  local  peritonitis  or  extend  and 
produce  the  general  form  of  the  disease.  Further,  it  is  not 
difficult  to  trace  the  possible  variations  which  would  accrue 
from  differences  in  degrees  of  acuteness  or  chronicity.  Thus 
an  acute  inflammation  would  lead  to  sloughing  or  gangrene : 
pus  might  be  produced,  and  be  pent  up  within  the  canal  or 
form  a  limited  abscess  around  the  organ.  Such  abscess  might 
burrow  in  various  directions,  or  burst  into  the  general  peri- 
toneal cavity.  Again,  an  acute  inflammation,  such  as  would 
cause  ulceration,  might  lead  to  perforation ;  and  should  no 
adhesions  have  formed  sufficient  to  shut  oft'  and  localise  the 
inflammatory  process  the  peritoneal  cavity  would  be  opened 
into. 

Other  pathological  lesions  would  depend  uj)on  the  particu- 
lar position  occupied  by  the  appendix.  Thus  its  close  proxi- 
mity to  the  iliac  vessels  may  cause  phlebitis,  or  thrombosis  of 
the  iliac  vein  :  or  the  vessels  ma}'  be  ulcerated  into,  and  a  fatal 
haemorrhage  result.  When  the  appendix  lies  across  the  psoas 
muscle,  inflammation  may  extend  to  that  muscle,  giving  rise 
to  flexion  and  fixation  of  the  thigh  upon  the  abdomen.  When 
the  appendix  is  long  and  hangs  into  the  pelvis,  it  may  form 
attachments  to  the  bladder  or  rectum,  and  subsequently 
establish  a  communication  with  either.  Abscesses  have  been 
known  in  cases  of  this  nature  to  be  discharged  either  per 
iirethram  or  yer  rectum. 

More  distant  lesions  are  sometimes  found,  mostly,  however, 
of  a  pyaemic  nature,  and  the  result  of  septic  absorption.  Thus 
instances  are  occasionally  forthcoming  of  abscess  formation 


494  THE    VERMIFORM   APPENDIX 

in  the  liver.  In  a  case  reported  by  Hector  Cameron/  death 
resulted  from  multiple  abscesses  in  the  liver.  The  patient 
during  life  had  had  well-marked  pysemic  symptoms,  and  an 
enlargement  of  the  liver  which  was  easily  observed. 

Lastly,  at  any  stage  the  inflammatory  process  may  subside, 
leaving  the  parts  either  healthy,  or  in  a  condition  to  light  up 
again  with  any  suitable  provocative.  This  latter  class  con- 
stitutes the  so-called  recurrent  or  relapsing  form. 

It  will  thus  be  seen  how  many  phases  a  purely  inflammatory 
process  may  present  and  how  numerous  become  the  divisions 
into  which  the  disease  might  be  divided.  For  practical  pur- 
poses it  is  possible  and  certainly  wise  to  attempt  some  sort  of 
a  classification,  but  it  is  better  to  remember  that  a  pathological 
condition  is  being  dealt  with  which,  while  it  may  assume  a 
simple  form  at  one  period,  may  at  any  moment  become  one 
of  extreme  gravity.  The  best  possible  division  would  be  one 
based  on  definite  causes,  as  tubercular  appendicitis  ;  simple 
ulcerative  appendicitis  ;  appendicitis  due  to  a  foreign  body ;  ap- 
pendicitis from  arterial  embolism  or  thrombosis ;  appendicitis 
from  kinking,  torsion,  or  compression  ;  specific  microbic  appen- 
dicitis, &c.  Such  a  classification,  however,  is  impossible  from 
the  fact  that  there  are  no  premonitory  signs,  or  symptoms 
pathognomonic  of  any  one  of  thess  causes,  nor  are  there 
pathological  lesions  peculiar  to  them.  Whatever  therefore 
be  the  nature  of  the  cause,  the  basis  of  classification  must 
be  either  definite  clinical  symptoms  or  distinct  pathological 
lesions.  The  latter  may  answer  the  purpose  of  the  patho- 
logist, but  until  our  knowledge  has  considerably  increased 
in  the  power  of  differentiating  symptoms,  we  can  probably 
get  no  further  than  to  consider  the  cases  under  the  three 
heads  of  acute,  subacute,  and  chronic  or  relapsing.  Even 
such  a  classification  conveys  but  very  imperfect  informa- 
tion, for  at  the  outset  of  any  case  we  can  never  tell  under 
which  heading  it  should  be  classed,  and,  what  is  still  more 
important,  the  name  in  no  sense  indicates  the  real  gravity 
of  the  case.  These  facts  will  become  clear  as  the  disease  is 
discussed. 

Etiology. — The  various  causes  which  may  prove  the  direct 
incentive  to  an  attack  of  appendicitis  have  already  been  in- 

'   Trans.  Path,  and  Clin.  Soc.  Glasgow,  1895,  vol.  v.  p.  125. 


APPEXUICITIS-ETIOLOr;  Y  4Ur, 

clicated,    but    a  little  more  detailed   description   of  them  is 
necessary. 

Many  causes  give  rise  to  inflammation  in  the  appendix 
which  would  have  no  similar  effect  in  the  case  of  the  caecum. 
The  reason  of  this  is  probably  to  be  sought  in  the  natural 
predisposition  which  an  ill-developed  and  degenerative  organ 
possesses. 

Bacillary  origin. — The  part  jDlayed  by  a  specific  micro- 
organism has  been  much  lauded  of  late  :  and  the  frequency 
with  which  the  hacillus  coli  communis  has  been  found  renders 
it  extremely  i^robable  that  the  disease  in  many  casjs 
owes  its  origin  to  this  microbe.  Whether  its  simple  pre- 
sence can  actually  initiate  the  disease  without  the  coexis- 
tence of  soms  primary  lesion  in  the  part  may  be  open  to 
question  ;  but  once  the  part  is  weakened  from  some  cause,  it 
is  more  than  probable  that  the  entrance  of  this  bacillus  into 
the  tissue  of  the  organ  lights  up  some  or  all  of  those  conditions 
which  are  included  under  the  general  term  of  appendicitis. 
The  bacillus,  it  must  be  remembered,  is  a  constant  occupant 
of  the  intestinal  canal,  and  as  such  has  read^'  access  to  the 
appendicular  canal.  It  is  therefore  practically  always  on 
the  spot,  and  ready  to  attack,  and  multiply  in,  any  tissue  that 
has  from  any  cause  become  more  or  less  devitalised. 

In  addition  to  this  particular  bacillus,  others  have  been 
discovered.  It  is  quite  possible  therefore  that  in  some  cases 
inflammation  has  arisen  from  pathogenic  microbes  other 
than  that  referred  to.  But  in  favour  of  the  preponderating 
effect  of  the  bacillus  coli  communis  is  the  fact  that  it  is 
almost  always  present,  and  in  some  cases  it  is  the  only  one 
found,  it  being  possible  to  obtain  a  pure  cultivation  of  it  from 
the  infected  part. 

Among  some  of  the  weakening  causes,  and  therefore  pre- 
paratory conditions  for  the  entrance  of  the  microbe,  are  such 
as  interfere  with  the  blood  or  nerve  supply  of  the  part.  Thus 
any  acute  kinking  or  bending  of  the  appendix,  or  torsion  of 
the  mesentery  may  interfere  with  the  blood  supply.  Similarly 
embolism  or  thrombosis  of  the  vessels  would  effect  a  like 
result.  Should  any  of  these  strangulating  or  occlusion  effects 
take  place  at  the  base  of  the  appendix,  the  whole  organ  would 
become  gangrenous.     Short  of  this  any  degree  of  necrosis  may 


496  THE   VERMIFORM    APPENDIX 

be  met  with.  It  is  hardly  possible  to  suppose  that  the  mere 
necrosis  of  the  whole  or  part  of  the  appendix  should  give  rise 
to  serious  symptoms ;  rather  must  it  be  that  the  devitalised 
part  becomes  infected  and  so  the  inflammatory  process  is 
started. 

Another  weakening  cause  is  probably  to  be  found  in  the 
irritative  effects  of  material  contained  within  the  appendicular 
canal.  Possibly  as  a  predisposing  or  actually  exciting  cause 
the  contents  of  the  canal  play  but  a  slender  part,  for  it  has 
already  been  shown  (see  page  491)  that  it  is  extremely  common 
for  fsecal  material  to  be  found  in  appendices,  in  cases  where 
there  has  been  no  lesion  centring  in  that  organ.  And 
as  regards  foreign  bodies,  their  presence  in  the  canal  must 
be  considered  rather  in  the  light  of  curiosities  than  as 
playing  any  part  in  the  production  of  disease.  Out  of  the 
169  cases  investigated  by  Fowler,  in  only  two  was  a  foreign 
body  found.  One  of  these  contained  a  true  enterolith,  and 
the  other  a  gall  stone.  Much  difference,  however,  exists  in 
the  nature  and  consistency  of  the  fsecal  accumulations  found. 
In  most  instances  they  are  more  like  small  lumps  of  putty, 
but  not  infrequently  some  are  met  with  hard  and  almost 
brittle.  It  is  not  difficult  to  understand  how  these  latter 
might  in  some  cases  prove  the  cause  of  ulceration  and  so 
create  a  weakened  spot  for  the  incursion  of  microbes. 

The  retrogressive  tendency  which  the  canal  has  to  become 
obliterated,  either  partially  or  completely,  results  sometimes 
in  the  inclusion  of  material  which  sooner  or  later  produces 
its  deleterious  influences  upon  the  involved  portion. 

Extension  of  inflammation  from  the  mucous  membrane 
of  the  cgecum  to  that  of  the  appendix  probably  takes  ^jlace 
in  some  cases  and  it  is  likely  that  in  some  of  these  cases 
occlusions,  partial  or  complete,  of  some  part  of  the  canal 
results,  with  consequent  distension  and  increased  inflammation 
of  the  distal  portion. 

Indiscretion  in  diet  and  over-exertion  are  ascribed  as 
causes  capable  of  evoking  a  fresh  attack  in  chronic  or  relaps- 
m<y  cases.  Such  a  cause  as  the  latter  probably  produces  its 
effect  by  tearing  or  stretching  adhesions. 

Among  rare  causes  of  appendicitis  must  be  mentioned 
tubercular  and  typhoid  ulceration.     Cases  of   actinomycosis 


APPENDICITIS  497 

are  recorded.  I  had  the  opportunity  of  seeing  an  example 
of  this  disease  in  the  wards  of  Scheming  in  the  Commune 
Hospital  at  Copenhagen.  Every  effort  hy  operation  had  been 
made  to  get  rid  of  the  disease,  but  still  the  wound  in  the  iliac 
region  copiously  discharged  pus  with  quantities  of  the  micro- 
organism in  it.  The  patient  was  greaily  emaciated,  and  died 
from  exhaustion.  A  case  is  also  recorded  by  Fairweather  ' 
in  which,  although  death  ensued,  considerable  improvement 
appears  to  have  resulted  from  the  use  of  the  iodides  of 
potassium  and  sodium. 

The  large  amount  of  lymphoid  tissue  in  the  mucous  and 
submucous  coats  may  play  a  part  in  initiating  the  disease 
in  certain  cases.  The  similarity  existing  between  these 
lymphoid  follicles  and  the  tonsils  has  led  to  the  belief  that 
inflammatory  affections  may  similarly  attack  the  former. 
It  is  possible  that  the  supposed  rheumatic  origin  of  the 
disease  finds  its  explanation  in  the  presence  of  this  tissue.^ 

A  factor  considered  of  some  importance  in  regard  to  the 
effect  it  has  upon  the  bacillus  coli  communis,  is  the  condition 
of  the  contents  of  the  large  intestine.  In  any  disease  of  the 
bowel,  but  more  particularly  in  chronic  constipation,  the 
bacillus  has  been  found  to  assume  a  more  virulent  character. 
It  is  thus  liable,  under  any  weakened  condition  of  the 
appendix,  to  more  readily  infect  it. 


CHAPTER   LXI 

APPENDICITIS  (continued),     symptoms  and  diagnosis 

Symptoms. — In  the  larger  proportion  of  cases  the  symptoms 
are  both  characteristic  and  distinctive  of  the  disease.  In  the 
matters  of  sex  and  age  it  shows  features  of  marked  proclivity. 

Sex. — In  the  169  cases  recorded  by  Fowler  the  disease 
occurred  142  times  in  males  and  35  in  females — that  is  to 
say,  in  the  proportion  of  four  of  the  former  to  one  of  the 
latter.  This  represents,  with  few  exceptions,  what  has  been 
found  to  be  the  ratio  in  other  series  of  published  cases. 

'  Brit.  Med.  Journ.  189ti,  vol.  i.  p.  1555. 
"  Ibid.  1895,  vol.  i.  p.  1142. 

K  K 


498  THE    VERMIFORM   APPENDIX 

Age. — The  disease  most  frequently  occurs  between  the 
years  of  10  and  30 ;  forty-three  of  Fowler's  169  cases 
were  between  20  and  25.  Roughly  it  may  be  estimated  that 
50  per  cent,  of  the  cases  occur  between  the  years  of  10 
and  25.  One  of  the  youngest  cases  is  that  of  a  child  aged 
2^  years,  recorded  by  Churton.^  It  died  of  perforation  of  the 
appendix.     The  oldest  of  Fowler's  series  is  68  years. 

Pain. — The  most  prominent  symptom  and  usually  the 
first  is  acute  pain,  felt,  in  the  majority  of  instances,  at  the 
time  of  seizure  and  for  half  an  hour  or  longer  after  in  the 
region  of  the  umbilicus  or  epigastrium.  It  is  likened  to  cramp. 
After  fixing  upon  the  upper  part  of  the  abdomen,  it  gradually 
diffuses  itself  over  the  entire  region,  and  finally  becomes 
located  in  the  right  iliac  fossa.  Its  occurrence  in  this  par- 
ticular region  renders  it  one  of  the  special  features  of  the 
disease. 

The  significance  of  the  pain  is  both  of  pathological  and 
physiological  interest.  It  doubtless  arises  in  the  first  place 
from  a  reflex  through  the  mesenteric  plexus,  the  solar  plexus, 
and  so  to  the  spinal  nerves  which  radiate  from  the  lower 
dorsal  and  upper  lumbar  regions ;  but  what  proves  the  direct 
exciting  cause  is  not  so  easy  to  determine.  Eushmore  ^ 
believes  that  the  initial  symptom  of  pain  really  indi- 
cates, not  the  commencement  of  the  disease,  but  its  last 
stage ;  that,  in  fact,  the  inflammation  has  reached  the 
peritoneum.  Jessop^  believes  that  there  are  several  cases 
in  which  pain  signifies  an  endeavour  on  the  part  of  the 
muscular  tunic  of  the  appendix  to  eject  from  the  canal  some 
offending  object  within  it,  or  some  of  its  pent-up  contents. 
To  pain  so  caused  the  term  '  appendicular  colic '  is  applied. 
The  cases  quoted  by  the  latter  surgeon  would  seem  to 
reasonably  support  the  view  that  there  are  cases  which  may 
be  considered  as  parallel  with  the  passage  of  gall  stones  down 
the  gall  duct,  or  a  renal  calculus  down  the  ureter.  A  portion 
of  the  appendix  becomes  gradually  distended  with  mucus, 
till  the  muscular  coat  is  stimulated  to  powerfully  contract 
and  endeavour  to  empty  its  contents  through  the  narrowed 

'  Brit.  Med.  Journ.  1895,  vol.  i.  p.  500. 

2  Annals  of  Surgerij,  1894,  vol.  xix.  p.  580. 

3  Brit.  Med.  Journ.  1894,  vol.  i.  p.  G27. 


A  PIM'.N  I  )ICITI8— 8  Y  MPTO.MS  499 

channel  at  its  proximal  end.  If  this  is  effected  the  colic 
disappears,  until  a  reaccumulation  leads  to  a  repetition  of 
the  same  process.  As,  however,  the  lesion  causing  the  pain 
is  really  a  pathological  one,  no  diminished  importance  can  be 
attached  to  it,  for  at  any  time  the  condition  may  pass  from  a 
non-inflammatory  one  into  a  true  appendicitis,  "with  all  the 
dangers  incident  to  that  affection  when  arising  from  other 
causes. 

Inasmuch  as  the  pain  which  is  latterly  felt  is  seated  over 
the  appendix,  any  abnormal  position  of  the  cgecum  will 
correspondingly  affect  the  locahty  of  the  pain.  In  not  a  few 
eases  this  has  been  illustrated  by  pain  in  the  left  iliac  fossa 
and  beneath  the  liver,  the  appendix  having  been  found  in 
these  situations. 

Nausea  and  vomiting. — Shortly  after  the  seizure  with  pain 
the  patient  frequently  vomits  or  complains  of  nausea.  The 
symptom  is  probably  more  connected  with  the  degree  of 
acuteness  of  the  pain  than  with  anything  else,  as  it  usually 
passes  off,  only  to  return  if  any  grave  lesion  occurs,  such  for 
instance  as  perforation  or  intestinal  obstruction. 

Temperature  and  j^ulse. — The  temperature  is  no  fixed 
feature.  A  chill  or  rigor  is  but  rarely  present.  In  most 
instances  there  is  some  rise  at  the  onset,  which,  however, 
may  soon  pass  off,  and  usually  does  so  in  the  course  of  two 
three  days,  in  cases  that  are  likely  soon  to  recover.  A 
continuous  rise  will  indicate  increasing  extension  of  the 
inflammation  with  possibly  pus  formation,  or  approaching 
perforation. 

There  are,  however,  numerous  exceptions  to  such  a  course. 
Perforation  has  taken  place  when  the  temperature  has  fallen 
to  normal ;  and  a  fetid  abscess  has  been  opened  after  the 
temperature  has  become  reduced.  A  temperature,  however, 
which  continues  to  rise  or  remain  elevated  after  the  third  or 
fourth  day,  should  be  watched  with  some  anxiety. 

The  pulse  as  a  rule,  with,  however,  many  exceptions, 
follows  pretty  much  the  temperature  in  rising  at  the  onset, 
and  subsiding  in  mild  cases  in  the  course  of  three  or  four 
days.  In  cases,  however,  which  are  progressive,  the  pulse 
shows  a  greater  constancy  in  its  action  than  the  temperature. 
Increase    of  rapidity   after   the   third    or    fourth    day  must 


too  THE   VERMIFORM   APPENDIX 

be  counted  as  a  grave  indication,  notwithstanding  the  fact 
that  such  a  rise  is  co-existent  with  a  fall  in  the  tempera- 
ture. In  cases  of  perforation  the  pulse  rate  is  usually 
high.  The  difficulties  associated  with  the  question  of  the 
temperature  and  the  pulse  are  concisely  expressed  by  Fowler  :  ^ 
'A  lowering  temperature  and  lessening  pulse  rate  is  not 
inconsistent  with  impending  ulceration,  perforation  of  the 
appendix  into  an.  unprotected  peritoneal  cavity,  complete 
gangrene  of  the  organ,  or  rupture  of  an  appendicular  abscess 
into  the  cavity  of  the  peritoneum.' 

The  hoivels. — In  some  cases  the  attack  has  been  preceded 
by  a  period  of  constipation,  which  may  give  way  during  the 
first  hours  of  the  seizure  to  more  or  less  of  diarrhoea.  In  other 
instances  diarrhoea  precedes  the  attack  ;  while  in  a  third 
class  there  has  been  no  intestinal  trouble. 

During  the  attack  the  bowels  may  become  constipated, 
but  often  normal  motions  take  place.  Should  the  inflamma- 
tion extend  to  the  caecum,  so  as  to  completely  paralyse  the 
walls  of  that  portion  of  the  intestine,  obstruction  would  result 
with  the  passage  of  neither  faeces  nor  flatus. 

Tenderness. — A  somewhat  important  symptom  is  the 
tenderness  elicited  by  pressure  over  the  seat  of  the  disease. 
At  the  earliest  stage  this  symptom  is  frequently  located  at  one 
particular  point,  situated  at  the  junction  of  a  line  drawn  from 
the  umbilicus  to  the  anterior  superior  iliac  spine  with  the 
outer  border  of  the  right  rectus  (McBurney's  point).  Pressure 
at  this  spot  causes  pain  of  variable  degrees  of  acuteness.  As 
the  disease  progresses  and  inflammation  extends,  the  area  of 
tenderness  also  enlarges,  and  pain  may  be  elicited  by  pressure 
anywhere  over  the  iliac  fossa  and  sometimes  more  generally 
over  the  abdomen.  Any  variation  in  the  normal  position  of 
the  caecum  and  appendix  will  affect  this  region  of  tenderness, 
since  palpation  of  the  abdominal  parietes  only  causes  pain  by 
reason  of  its  direct  effect  upon  the  inflamed  area. 

In  cases  of  a  long  appendix  hanging  into  the  pelvis,  tender- 
ness may  be  found  on  rectal  or  vaginal  examination ;  but 
under  ordinary  circumstances  this  method  of  investigation 
affords  little  or  no  assistance. 

It  occasionally  happens,  in  palpating  the  abdomen,  that  the 

I  Page  153. 


A  PPExXDICITIS— SYMPTOMS  501 

right  rectus  muscle  is  felt  to  be  more  or  less  rigid.  This  is 
due  to  the  involvement  of  the  peritoneum  lining  it.  Similarly, 
should  the  appendix  rest  upon  the  psoas,  some  inflammatory 
irritation  of  the  muscle  would  lead  to  flexion  and  fixation  of 
the  thigh  upon  the  abdomen. 

Tumour. — Manipulation  of  the  parietes  may  reveal  the 
existence  of  a  swelling.  This  is  more  likely  to  be  detected  if 
the  abdominal  walls  are  relaxed  by  the  administration  of  an 
anaesthetic.  It  is  a  comparatively  common  symptom,  although 
in  many  cases  it  may  not  amount  to  more  than  an  ill-defined 
fulness.  When  not  prominent  it  is  most  probably  due  to 
the  adhesion  and  matting  of  the  parts,  with  possibly  some 
thickening  the  result  of  cedema.  In  more  evident  indications 
of  a  swelling,  the  cause  is  probably  an  abscess. 

In  addition  to  the  localised  swelling  in  the  iliac  fossa, 
the  abdomen  itself  is  sometimes  distended  and  tympanitic 
on  percussion.  This  is  probably  due  to  some  commencing 
peritonitis ;  but  as  the  other  symptoms  subside,  it  too  dis- 
appears. 

The  patient's  general  condition  soon  shows  considerable 
change.  Loss  of  appetite  leads  to  emaciation,  the  face  be- 
comes pale,  the  tongue  coated,  and  the  patient  presents  the 
aspect  of  being  acutely  ill. 

A  symptom  occasionally,  though  rarely,  present  is  some 
pain  connected  with  micturition.  Its  origin  is  usually  due  to 
the  irritative  effects  of  an  appendicitis  situated  in  the  pelvis. 
Barling '  mentions  having  met  with  it  in  five  cases,  all 
males. 

Occasionally  the  patient  suffers  from  constantly  recurring 
chills  or  rigors  ;  such  symptoms  indicate  septic  absorption, 
and  may  result  in  abscess  formation  in  the  liver.  In  a  case 
recorded  by  Harte,^  while  the  early  symptoms  were  those  of 
appendicitis,  the  later  ones  and  those  which  caused  death  were 
all  directed  to  the  region  of  the  liver,  and  to  pyaemia.  At  the 
post  mortem  the  liver  was  found  slightly  enlarged,  and  filled 
with  a  large  number  of  metastatic  abscesses. 

In  progressive  cases — those  in  which  the  inflammatory 
process  does  not  subside  after  the  first  three  or  four  days — 

'  Brit.  Med.  Journ.  1895,  vol.  i.  p.  1136. 

-  Annals  nf  Surgery,  1894,  vol.  xx.  p.  423. 


502  THE   VERMIFOEM  APPENDIX 

other  symptoms  arise  in  connection,  in  most  instances,  with 
the  formation  of  an  abscess,  which  usually  tends  to  find  its 
way  to  the  surface.  The  skin  in  the  loin  or  inguinal  region 
becomes  reddened  and  oedematous,  with  increased  tenderness. 
In  cases  where  the  abscess  bursts  without  being  previously 
opened,  it  may  burrow  between  the  parietal  muscles  and 
evacuate  itself  at  some  distance  from  the  seat  of  the  disease. 
In  one  such  case  I  found  the  abscess  discharging  itself  through 
an  opening  over  the  left  iliac  fossa.  In  enlarging  the  orifice, 
an  aperture  in  the  muscles  was  detected  which  communicated 
with  a  sinus  leading  across  the  abdomen  to  the  usual  seat. 

Perforation  of  the  appendix  sometimes  takes  place  in  cases 
where  the  disease  is  supposed  to  be  subsiding  or  quiescent. 
There  is  then  a  sudden  outbreak  of  acute  symptoms,  with  all 
the  usual  accompaniments  of  commencing  acute  peritonitis. 
The  bursting  of  an  abscess  into  the  general  peritoneal  cavity 
will  also  be  associated  with  an  exacerbation  of  the  symptoms. 

Abscesses  which  burst  or  have  been  opened  sometimes 
leave  intractable  discharging  sinuses.  The  purulent  matter 
his  frequently  a  fsecal  odour,  showing  that  in  all  probability 
there  has  been  or  still  is  a  fistulous  communication  v.'ith  the 
bowel.  In  some  of  these  cases  a  fsecal  concretion  is  found 
at  the  bottom  of  the  sinus.  Two  such  fell  under  my  own 
observation. 

Where  after  the  lapse  of  three  or  four  days  all  symptoms 
subside,  it  may  be  hoped  that  the  patient  is  convalescent. 
However,  as  regards  the  seat  of  disease,  one  of  two  results 
may  be  happening  :  either  there  is  a  complete  return  to  the 
normal  healthy  condition,  or  there  is  a  perpetuation  of  some 
chronic  inflammatory  process  which  will  lie  dormant  until 
excited  into  renewed  activity  by  some  fresh  agency.  The 
cases  included  under  this  latter  class  constitute  those  known 
as  chronic,  recrudescent  or  relapsing. 

In  instances  of  this  chronic  class  it  is  not  infrequent  to 
find  that,  while  all  prominent  symptoms  have  disappeared, 
there  hngers  a  variable  degree  of  tenderness  about  the  ihac 
fossa  when  deep  pressure  is  made  upon  it.  Or  it  may  be  that 
as  the  result  of  excessive  exercise,  or  indiscretion  in  diet,  the 
patient  is  himself  conscious  of  some  discomfort  in  the  region. 
From  either  of  these  latter  causes,  as  well  as  from  others  un- 


PLATE    XXIV. 


Fig.  63  — C/ECUM  AND  Vermiform  Appendix.— The  piece  of  whalebone  Indicates  a 
perforation  which  resulted  from  a  concretion,  and  led  to  acute  peritonitis. 
(IV. I. M.,  Glas.) 


APPENDICITIS— DIAGNOSIS  OOa 

lvno^Yn,  an  acute  attack  is  sometimes  set  up,  when  all  the 
symptoms  from  which  the  patient  suffered  in  the  initial 
attack  are  repeated,  Eometimes  to  a  less  degree  of  severity, 
but  as  frequently  to  a  greater. 

These  recurrent  or  relapsing  attacks  take  place  at  variable 
intervals  of  time.  Sometimes  a  patient  may  suffer  from 
several  attacks  in  a  year  ;  in  others,  again,  the  frequency  with 
which  they  recur  renders  the  patient  a  chronic  invalid.  The 
ultimate  result  in  these  cases  it  is  never  possible  to  predict. 
Sometimes  after  a  series  of  attacks  the  patient  ceases  to  be 
any  longer  troubled  with  a  repetition ;  in  other  cases  an 
attack  finally  comes  which  ends  in  acute  peritonitis  or  acute 
intestinal  obstruction. 

Diagnosis. — Few  intra-abdominal  cases  present  less  diffi- 
culty in  diagnosis  than  those  of  typical  acute  appendicitis. 
A  patient  seized  with  sudden  acute  pain  located  at  first  in  the 
neighbourhood  of  the  umbilicus,  and  subsequently,  or  some- 
times at  the  outset,  in  the  right  iliac  fossa ;  with  nausea  and 
vomiting ;  with  tenderness  in  the  region  of  the  appendix  ;  and 
with  some  rise  of  temperature  and  acceleration  of  pulse,  will, 
in  nineteen  cases  out  of  twenty,  be  the  subject  of  an  acute 
attack  of  appendicitis.  At  a  later  stage  some  fulness  may  be 
detected  in  the  right  iliac  fossa. 

It  is  right  to  indicate  here  that  in  examination  of  the 
abdomen  by  palpation  all  due  care  and  gentleness  should  be 
employed  in  making  pressure  upon  the  seat  of  disease. 
Where  the  adhesions  which  shut  off  a  localised  abscess  are 
recent,  they  are  likely  to  be  slender  and  easily  broken  down. 
Hence  it  may  easily  happen  that  an  abscess  ruptures 
into  the  general  peritoneal  cavity.  Such  an  accident  during 
examination  would  be  marked  by  a  sudden  diminution  in  the 
feeling  of  resistance,  and  in  the  partial  disappearance  of  the 
swelling.  A  case  is  recorded  by  Daniel '  where  this  accident 
happened.  With  commendable  promptitude  the  abdomen 
was  opened,  and  the  extrava sated  pus  removed  by  irrigation 
and  sponging.     The  patient  made  an  uninterrupted  recovery. 

The  association  of  sudden  acute  pain  with  vomiting  and 
nausea  in  cases  of  hepatic  or  nephritic  colic  may  sometimes 
mislead.     There   is,    however,    usually   the   absence   of  any 

'  Brit.  Med.  Journ.  1894,  vol.  ii.  p.  531. 


504  THE   VERMIFORM  APPENDIX 

marked  distant  reflex  pain  such  as  is  peculiar  to  either  of  these 
conditions,  and  the  tenderness  in  the  seat  of  the  appendix  is 
absent  in  the  passage  of  bihary  or  renal  calculi. 

A  case  of  a  somewhat  exceptional  character  was  transferred 
to  my  male  ward  as  one  of  abscess  from  appendicitis.  The 
swelling  presented  the  characters  and  occupied  the  position 
of  an  appendicular  abscess.  The  history  of  the  case  also  lent 
support  to  the  diagnosis.  However,  on  opening  the  abscess 
I  came  upon  a  fish  bone  which  had  apparently  worked  its  way 
out  through  the  large  bowel  near  the  commencement  of  the 
ascending  colon. ^ 

Mistakes  are  liable  to  be  made  when  the  caecum  and 
appendix  are  not  normally  situated  in  the  right  iliac  fossa. 
Other  symptoms  being  typical,  tenderness  and  pain  located 
in  the  left  iliac  fossa,  or  even  beneath  the  liver,  should  lead 
to  the  suspicion  of  an  abnormally  disposed  appendix. 

Cases  of  intestinal  obstruction  have  been  mistaken  for 
appendicitis,  and  in  some  of  these  the  great  similarit}^  of 
symptoms  renders  it  very  difficult,  if  not  impossible,  to  differ- 
entiate. Fowler  records  three  examples.  In  one  the  patient 
was  found  to  have  the  ileum  strangulated  by  a  diverticulum. 
In  a  second  the  small  intestine  had  been  drawn  down  by  old 
adhesions  into  the  pelvis ;  and  in  the  third  there  was  a 
strangulated  internal  hernia.  In  all  three  of  these  cases  the 
misleading  feature  was  the  location  of  the  pain  in  the  right 
iliac  region. 

Cases  have  occasionally  been  mistaken  for  typhoid  fever, 
and  as  such  admitted  into  hospital.  The  converse  also  has 
occurred.  A  careful  examination,  however,  usually  reveals  the 
true  nature  of  the  affection. 

The  clinical  history  of  only  two  cases  is  given — one  acute, 
the  other  relapsing.  The  excessive  variability  which  exists  in 
the  mode  of  onset  as  well  as  in  the  progress  of  the  disease 
renders  it  impossible  to  present  any  illustration  which  can  be 
called  in  any  way  specially  representative. 

Case  C. — Acute  appendicitis:  abscess  formation :  incision.      Recovery. 

W.  B.,  aged  27  years,  awoke  at  two  o'clock  on  the  afternoon  of  Friday, 

July  17,  on  account  of  a  colicky  pain  in  the  umbilical  region,  which  also 

'  Trans.  Path,  and  Clin.  Soc.  Glasgow.  1895,  vol.  v.  p.  197. 


ArPENDICITIS  505 

passed  up  and  down  the  abdomen.  He  took  a  teaspoonful  of  medicine 
f^iven  him,  which  he  soon  vomited  ;  the  pain,  however,  in  the  abdomen 
ceased.  On  the  following  morning,  Saturday,  the  18th,  a  second  and  quite 
different  variety  of  pain  seized  him.  It  was  of  a  constant,  throbbing, 
cutting  character  in  the  right  iliac  region.  The  umbilical  colicky  pain 
also  returned  at  intervals.  He  was  now  confined  to  his  bed.  He  did  not 
vomit,  and  took  but  scanty  nourishment ;  the  bowels  moved  once  scantily. 
When  admitted  into  hospital  on  Monday,  the  20th,  examination  of  the 
abdomen  revealed  an  area  of  exquisite  tenderness,  about  three  by  three 
inches,  chiefly  in  the  right  iliac  region,  but  extending  into  the  hypo- 
gastric region.  There  was  a  marked  sense  of  resistance,  with  dulness  on 
percussion,  and  a  reddened  condition  of  the  skin  quite  sharply  limited  to 
the  above  area.  Tongue  coated,  no  appetite,  bowels  constipated,  pulse 
108,  moderate  and  soft ;  temperature  102-4°  F. 

Operation. — A  crescentic  incision,  with  its  convexity  down  and  out- 
wards, was  made  over  the  reddened  area.  The  subcutaneous  tissue  and 
all  the  muscles  of  the  abdominal  wall  were  found  densely  infiltrated  with 
serum,  rendering  them  very  firm.  A  sausage- shaped  tumoiu:  was  incised, 
when  a  muddy,  fetid  pus  escaped  with  a  few  bubbles  of  gas,  showing  the 
existence  of  a  small  abscess  cavity  surrounding  a  central  somewhat  cylin- 
drical body,  which  was  the  appendix  lying  at  the  bottom  of  the  abscess, 
soft,  dull,  and  greenish-white  in  appearance.  The  wound  was  irrigated 
with  hot  sterilised  water,  packed  with  iodoform  gauze,  and  a  quantity  of 
absorbent  antiseptic  dressing  applied.  Eecovery  was  uninterrupted. 
(Eisendrath,  '  Annals  of  Surgery,'  1892,  vol.  xv.  p.  364.) 

Casr  CI. — Relapsing  a2:>2)endicitis  :  appendicectomy.     Recovery. 

C.  G.,  an  miusually  well- developed  and  healthy-looking  j'oung  man 
of  21  years,  suffered  from  four  attacks  of  appendicitis  within  ten  months. 
Two  of  these  attacks  were  so  severe  as  apparently  to  threaten  life ;  two 
were  much  milder.  The  first  attack  began  on  June  4,  1889,  lasted  only  a 
few  days,  and  was  subdued  by  rest  and  a  few  doses  of  an  opiate.  The 
symptoms  were  constipation,  coated  tongue,  pain  in  the  right  iliac  fossa, 
tenderness  to  pressure  in  the  same  region,  a  slight  degree  of  abdominal 
distension,  and  slightly  elevated  temperature.  The  second  attack  began 
on  June  14, 1889,  after  a  sharp  game  at  lawn  tennis.  It  was  a  very  severe 
seizure  ;  the  temperature  ran  up  to  and  over  103°  F. ;  the  pulse  was  rapid, 
and  vomiting  was  continuous  for  several  days ;  there  was  marked  consti- 
pation, a  coated  tongue,  universal  abdominal  distension,  tenderness,  and 
tympanitic  percussion  note.  Pain  and  tenderness  in  right  iliac  fossa  were 
most  acute.  Patient,  after  being  seriously  ill  for  nearly  a  week,  gradually 
recovered  as  before,  being  treated  by  rest,  opiates,  poultices,  and  limited 
diet.  A  third  (very  severe)  attack  occurred  on  October  7,  and  a  fourth 
(mild)  one  on  April  2,  1890. 

Op)eration. — After  the  patient  was  well  out  of  the  fourth  attack,  and 
in  what  maybe  termed  the  quiescent  period,  appendicectomy  was  performed. 
The  appendix  was  found  much  distended  and  deeply  attached.  In  re- 
moving it  there  were  considerable  adhesions,  both  firm  and  slight,  and  a 


506  THE    VERMIFORM   APPExNDIX 

good  deal  of  oozing  took  place  on  their  severance.  The  wound  healed  by 
first  intention,  and  the  patient  was  allowed  to  get  about  after  a  month's 
confinement. 

The  patient  when  seen  a  year  after  the  operation  was  in  perfect  health, 
and  had  been  so  since  the  operation.  (Alexander  Napier  and  A.  Ernest 
Maylard,  '  Trans.  Path.  Clin.  Soc.  Glasgow,'  1891,  vol.  iii.  p.  284.) 


CHAPTEE   LXII 

APPENDICITIS  (continued),    peognosis  and  treatment 

Prognosis. — The  many  possibilities  which  exist  at  the  out- 
set of  any  appendicular  attack  render  it  impossible  at  this 
stage  to  predict  what  may  be  the  ultimate  issue.  Ex- 
cessive acuteness  of  the  early  symptoms  does  not  necessarily 
imply  increased  gravity  of  the  case  ;  neither  does  mildness 
in  their  manifestation  preclude  the  possibility  of  the  gravest 
result. 

The  most  favourable  results  may  be  expected,  in  cases  of 
early  subsidence  of  the  symptoms,  after  twenty-four  or  forty- 
eight  hours.  If  on  the  other  hand  the  disease  progresses, 
increase  of  the  symptoms  will  be  observed  after  the  third 
or  fourth  day.  The  importance  of  the  temperature  and  pulse 
on  and  after  these  days  has  already  been  referred  to.  Should 
both  pulse  and  temperature  fall,  accompanied  with  a  subsi- 
dence of  other  symptoms,  a  favourable  result  may  be  looked 
for.  A  falling  temperature,  however,  accompanied  by  a  rapid 
or  rising  pulse  rate  and  little  or  no  remission  of  the  symptoms, 
should  be  considered  as  indicative  of  some  gravity. 

Increased  tenderness  or  swelling  in  the  iliac  region  indi- 
cates abscess  formation.  Evacuation  of  the  abscess  cavity 
may  be  followed  by  rapid  recovery;  there  is,  however,  the 
possibility  of  a  fistula  remaining  for  some  time. 

When  the  patient  has  recovered  from  an  attack,  the  ques- 
tion arises  whether  there  is  a  complete  cure  or  whether  some 
inflammatory  mischief  remains.  It  may  be  considered  indi- 
cative of  the  latter  result  when  some  undue  tenderness  lingers 
in  the  iliac  region.  In  such  cases  a  recurrent  attack  is  only 
too  probable   at    no    distant   date.      The  following  remarks 


APPENDICITIS— PROGNOSIS  607 

by  Treves  '  are  of  value  in  connection  with  the  question  of 
recrudescence  :  '  If  a  hirge  series  of  cases  of  this  affection  l)e 
passed  in  review,  it  will  be  found  that  the  number  of  instances 
in  which  there  has  been  only  one  attack  is  much  greater  than 
that  in  which  there  have  been  several  attacks.  In  a  certain 
proportion  of  the  examples  of  a  single  attack  there  has  been 
an  abscess,  and  the  great  majority  of  the  subjects  of  typhlitis 
who  have  passed  through  the  stage  of  suppuration  are  thereby 
rendered  free  from  any  further  attacks.  The  cause  of  the 
trouble  has  been  removed  by  the  suppurative  process.  The 
abscess  cavity  may  apparently  heal,  and  what  is  improperly 
called  a  second  abscess  may  form ;  but  that  does  not  as  a 
rule  represent  any  fresh  mischief  at  the  original  seat  of 
disease.' 

Eichardson,^  in  the  181  cases  observed  by  him,  met  with 
46  where  there  was  the  history  of  a  previous  attack  ;  that  is 
to  say,  a  relapse  took  place  in  25  per  cent,  of  the  cases.  In 
Fowler's  cases  there  were  35  which  relapsed  out  of  the  154 — 
making  therefore  a  very  similar  average. 

Prognosis  in  regard  to  operation. — From  certain  aspects  it 
is  possible  to  express  a  tolerably  definite  opinion  regarding 
the  advantage  or  otherwise  of  operations.  Most  difficulty 
arises,  if  not  positive  error,  when  an  attempt  is  made  to  com- 
pare, in  toto,  by  statistics  the  relative  advantages  of  purely 
medical  treatment,  and  operative.  Thus  Fitz  ^  gives  a  mor- 
tality of  11  per  cent,  in  cases  treated  medically,  and  40  per 
cent,  for  those  surgically  dealt  with.  The  most  superficial 
consideration  could  only  deduce  from  such  data  the  supposed 
advantage  of  medical  treatment  over  surgical.  If  a  compari- 
son of  the  kind  were  to  have  any  practical  value,  every  case 
of  a  certain  series  should  be  dealt  with  medically,  and  every 
case  of  another  series  surgically.  As  a  matter  of  fact,  how- 
ever, what  really  happens  is,  that  the  simple  uncomplicated 
cases  receive  mostly  purely  medical  treatment,  while  the 
severe  and  frequently  complicated  are  relegated  to  the  surgeon. 
If  therefore  any  just  appreciation  of  the  valae  of  operation 
is  to  be  obtained,  it  can  only  be  on  the  surgical  treatment  of 

'  Brit.  Med.  Jonrn.  1895,  vol.  i.  p.  517. 

^  American  Journal  of  the  Medical  Sciences,  1894,  vol.  cvii.  p.  22. 

'  Boston  Med.  and  Surg.  Journ.  1890,  vol.  cxxii.  p.  620. 


508  THE   VERMIFORM   APPENDIX 

cases  which  either  fail  to  amend  under  medical  treatment, 
or  present  features  which  it  is  deemed  inexpedient  to  allow  to 
ran  an  uninterrupted  course. 

First  as  regards  relapsing  cases,  it  can  be  confidently 
asserted  that  the  removal  of  the  appendix  will  permanently 
remove  the  disease,  and  that  this  can  be  effected  with  a 
minimum  degree  of  risk  as  regards  the  operation  itself.  The 
following  statistics  sufficiently  attest  this.  In  the  85  relapsing 
cases  of  Fowler's  series,'  27  were  operated  upon  during  the 
quiescent  period,  and  8  during  the  acute  stage.  There  were 
two  deaths,  and  these  were  attributed,  one  to  septic  peritonitis 
which  existed  prior  to  operation,  and  the  other  to  tubercular 
ulceration  of  the  ileum.  Treves  ^  gives  32  cases  of  appen- 
dicectomy  for  relapsing  appendicitis,  with  one  death.  Similar 
good  results  are  recorded  by  other  surgeons.  The  operation, 
therefore,  undertaken  by  an  experienced  and  skilled  operator 
is  a  safe  one  and  remedial. 

Operations  performed  during  the  acute  stage  of  the  disease 
hold  out  a  much  less  hopeful  prospect.  This,  however,  is 
largely  affected  by  the  conditions  that  are  found  at  the  opera- 
tion. Thus  in  Morris's  statistics  ^  of  appendicectomy  there 
were  48  cases  operated  upon.  In  28  there  were  neither  adhe- 
sions nor  exudation,  and  all  recovered  ;  in  9  there  were  adhe- 
sions but  no  exudate,  also  all  recovered  ;  in  11  there  was  present 
a  purulent  exudate,  and  4  deaths  occurred.  In  Eichardson's 
cases,  out  of  88  operated  upon  when  acute,  30  died.  In 
Fowler's  119  acute  cases  there  were  41  deaths,  4  of  which  were 
directly  attributable  to  the  operation. 

The  least  that  can  be  hoped  for  by  operation  is  when 
peritonitis  has  already  set  in.  Operation,  however,  holds  out 
the  only  hope,  and  has  proved  successful.  Lane  ^records  a 
good  result  where  there  was  general  acute  suppurative  peri- 
tonitis, and  McBarney^  reports  a  similar  success.  Lockwood*^ 
also  contributes  a  successful  case,  where  acute  general  septic 
peritonitis  followed  upon  gangrene  or  ulceration  of  the  appen- 
dix.    Moynihan  "^  records  the  case  of  a  boy  aged  13,  who  had 

•  Page  570.  ^  Brit.  Med.  Joiirn.  1895,  vol.  i.  p.  517. 
^  Amials  of  Surgerxj,  1893,  vol.  xviii.  p.  .377. 

■•  Brit.  Med.  Journ.  1894,  vol.  i.  p.  354. 

*  Annals  of  Surgerij,  1893,  vol.  xviii.  p.  42. 

s  Brit.  Med.  Journ.  1890,  vol.  i.  p.  731.  '  Ibid.  p.  1387. 


APPENDICITIS— TREATMENT  509 

suffered  for  three  and  a  half  days  from  acute  aj^pendicitis, 
perforation  occurring  towards  the  end  of  the  third  day.  The 
abdomen  was  opened  by  a  median  incision,  and  the  peritoneal 
cavity,  which  was  found  to  contain  offensive  pus,  was  thoroughly 
cleansed  and  drained.  By  a  separate  incision  the  abscess 
cavity  over  the  appendix  was  opened,  cleansed,  and  drained. 
A  prolonged  convalescence  eventuated  in  com^jlete  recovery. 

In  cases  of  abscesses  which  are  opened  externally,  the 
result  of  the  operation  is  almost  always  favourable. 

So  far,  therefore,  as  prognosis  is  affected  by  removal  of 
the  appendix,  it  may  be  briefly  summed  up  by  saying  that 
appendicectomy  is  safest  during  the  quiescent  periods  of  re- 
lapsing cases,  and  at  an  early  date  in  acute  cases  ;  that  is  to 
say,  before  the  appendix  has  contracted  adhesions,  and  before 
there  is  any  exudation.  It  is  doubtful  in  acute  cases  with  sup- 
puration more  or  less  advanced,  while  it  is  almost  hopeless  in 
general  peritonitis. 

Treatmant. — Probably  in  no  disease  does  greater  divero-ence 
of  opinion  exist  as  to  treatment  than  obtains  in  connection 
with  appendicitis.  Between  the  two  extreme  views  of  never 
to  operate  and  always  to  operate  there  exists  a  mass  of  equally 
conflicting  opinions,  which  renders  it  all  but  impossible  to 
formulate  any  but  the  most  general  lines  for  guidance. 

It  must  be  remembered  that  the  majority  of  cases  recover 
and  the  true  object  of  operative  intervention  should  be  to  save 
those  which  nature's  efforts  cannot,  however  much  they  may 
be  assisted  by  medical  treatment.  The  difficulty  of  course 
is  to  know  whether  these  palliative  efforts  will  prove  ineffectual 
and  when. 

I  am  disposed  to  think  that  most  surgeons  in  this  country 
are  not  likely  to  operate  or  be  called  upon  to  operate  within 
the  first  forty-eight  hours  of  an  ordinary  acute  case.  I  ven- 
ture to  think  that  were  we  in  the  position  of  the  patient  and 
not  in  that  of  the  practitioner,  we  should  "certainly  refuse  the 
operation  of  appendicectomy  at  the  outset.  And,  further  I 
believe  that  the  consensus  of  opinion  among  surgeons  on  this 
side  of  the  Atlantic  is  that  operation  should  not  be  performed 
during  the  acute  stage,  excepting  only  on  the  sudden  onset  of 
untoward  symptoms  indicative  of  perforation,  or  the  bursting 
of  an  abscess  into  the  peritoneal  cavity.     This  non-interference 


510  THE    VERMIFORM   APPENDIX 

in  the  earlier  stages  of  the  disease  does  not,  however,  remove 
the  surgical  responsibility  which  attaches  to  the  case  from  its 
very  commencement.  The  possibility  that  at  any  time  urgent 
symptoms  may  call  for  immediate  operation  renders  it  impera- 
tive that  these  cases  should  from  the  first  be  under  the  charge 
of  the  surgeon  and  not  the  physician.  In  claiming  a  surgical 
supervision  of  these  eases  it  is  not  meant  that  they  necessarily 
require  operative  treatment,  as  is  sometimes  erroneously  sup- 
posed and  asserted,  but  that  the  surgeon's  knowledge  of  the 
case  from  the  first  better  prepares  him  for  any  contingency 
which  may  arise,  and  admits  of  that  promptness  of  action 
which  alone  can  prove  the  means  in  many  cases  of  saving  life. 

If,  then,  only  exceptional  complications  demand  operation 
during  the  acute  stage  of  the  disease,  what  is  to  be  said  of 
those  cases  which  become  chronic  or  relapse  ?  Should  they  be 
operated  upon  ? 

In  the  first  place  the  operation  of  appendicectomy,  when 
conducted  in  the  quiescent  ctage  of  the  disease  and  by  com- 
petent operators,  has  been  shown  to  be  exceptionally  safe. 
The  question  of  weakening  the  abdominal  parietes  is  but 
slight  when  proper  attention  is  devoted  to  the  primary  incision. 
Cases  of  ventral  hernia  occasionally  occur.  Treves  ^  computes 
them  at  about  5  per  cent. 

Should  appendicsctomy  be  performed  in  a  case  which  has 
recurred  once,  or  should  it  be  delayed  till  after  a  second 
recurrence,  or  a  third,  and  so  on  ?  Possibly  the  proper  way 
to  answer  the  question  is  to  consider  the  condition  of  the 
patient  after  the  attack  :  whether  there  is  a  return  to  complete 
health,  or  whether  there  is  some  lingering  pain,  tenderness,  or 
sense  of  discomfort  in  the  region  of  the  appendix.  In  the 
former  case  it  is  possible  that  another  attack  will  not  be  forth- 
coming ;  in  the  latter  it  is  probable  it  will.  Hence  it  would 
appear  a  reasonable  indication  for  the  operation  when  the 
patient  seems  to  suffer  from  persistent  mischief  which,  if  it 
does  not  keep  him  continually  more  or  less  an  invalid,  at 
least  subjects  him  to  attacks  which  will  be  troublesome  and 
may  at  any  time  prove  dangerous. 

A  somewhat  more  difficult  question  to  answer  is  the 
advisability  or  not  of  cutting  down  upon  a  fulness  or  tumoar 
'  Lancet,  1896,  vol.  i.  p.  16. 


APPENDICITIS— TREATMENT  51 1 

felt  to  exist  in  the  iliac  fossa.  Assuming  that  it  is  large 
enough  to  indicate  a  collection  of  exudation,  pus,  or  otherwise, 
should  it  he  allowed  to  progress  until  there  is  unmistakable 
evidence  of  its  proximity  to  the  parietes  before  being  opened ; 
or  should  an  endeavour  be  made  to  reach  it  and  empty  it 
before  any  such  evidence  exists  ?  Here,  again,  I  venture  to 
think  the  consensus  of  opinion  among  surgeons  in  this  country 
is  in  favour  of  delay  rather  than  otherwise.  That  is  to  say, 
it  is  considered  advisable  to  ensure  the  adhesion  of  the  parietal 
peritoneum  to  the  advancing  abscess  cavity  before  opening. 
The  argument  in  favour  of  not  delaying  is  the  possibility  of 
the  abscess  bursting  into  the  peritoneal  cavity.  But  the 
question  is  whether  there  is  not  greater  danger  of  producing 
that  result  by  the  very  measure  which  is  adopted  to  prevent 
it.  However,  the  skill  of  the  operator  is  a  not  unimportant 
factor  in  forming  a  decision,  for  there  is  much  to  show  that 
a  careful  deep  dissection  may  be  carried  out  with  almost  as 
much  safety  as  if  no  such  dissection  were  required.  It  must 
be  remembered  that  in  some  of  these  cases  of  abscess  forma- 
tion the  seat  of  suppuration  is  probably  retroperitoneal,  and 
that  therefore  there  is  less  danger  of  the  general  peritoneal 
cavity  being  opened  than  where  the  abscess  is  intraperitoneal, 
its  boundaries  consisting  of  adhesions  variable  in  extent  and 
in  strength. 

If,  then,  operation  be  not  deemed  the  proper  expedient  to 
adopt  within  the  first  forty-eight  hours  of  an  ordinary  acute 
case,  what  treatment  should  be  employed  ?  Advice  in  this 
respect  is  almost  as  confusing  as  in  the  case  of  operation  ; 
fortunately,  however  divergent  the  opinions,  no  very  great 
harm  under  any  particular  method  can  accrue. 

Accepting  only  the  opinion  of  those  who  from  a  long  and 
large  experience  are  alone  competent  advisers,  the  following 
lines  in  treatment  may  be  laid  down : 

The  patient  is  put  to  bed  and  kept  as  much  as  possible  at 
rest.  The  pain  in  the  iliac  region  may  be  relieved  by  the 
application  of  a  soft  linseed  meal  poultice  of  sufHcient  tem- 
perature to  be  comfortably  borne.  All  applications  likely  to 
irritate  the  skin  should  be  avoided.  Much  as  poultices  are 
distasteful  to  the  surgeon,  and  in  most  cases  justly  so,  there 
is  nothing  that  proves  so  soothing  in  effect. 


512  THE   VERMIFORM   APPENDIX 

No  solid  food  should  be  administered,  but  the  patient's 
strength  kept  up  by  fluids,  such  a.s  chicken  broth,  beef  tea, 
whey,  and  suchlike.  Milk,  from  the  fact  of  its  curdling  in 
the  stomach,  and  becoming  thereby  largely  of  the  nature  of  a 
solid,  should  be  avoided.  This  avoidance  of  milk  is  strongly 
advocated  by  Thornley  Stoker.^  The  same  writer  deprecates 
the  use  of  ice  for  thirst,  but  recommends  frequent  rinsing  of 
the  mouth  with  hot  water,  and  swallowing  occasionally  a  tea- 
spoonful  of  warm  water. 

Whether  opium  in  some  shape  or  form  should  be  given 
is  a  much  disputed  point.  The  majority,  at  least  of  sur- 
geons, are  against  its  employment.  The  chief  disadvantage 
of  its  use  is  the  likelihood  of  symptoms  being  masked,  and 
so  subsidence  of  the  disease  assumed,  when  in  reality  grave 
progress  may  be  taking  place.  It  is  easy  to  write  what 
should  be  done,  but  it  is  difficult  when  face  to  face  with  the 
sufferer  to  withhold  the  hand  from  what  will  certainly  give 
relief.  However,  when  opium  is  administered,  if  possible 
greater  watchfulness  should  be  exercised,  in  order  to  note  the 
first  indications  of  any  untoward  complication  and  to  properly 
discount  the  influences  produced  by  the  drug. 

Excluding  cases  where  the  onset  is  marked  by  undue 
severity,  no  treatment  is  fraught  with  better  results  than  that 
which  aims  at  relieving  the  bowels  either  by  the  administration 
of  some  saline  aperient  or  the  careful  use  of  warm- water 
enemata. 

As  regards  purgatives,  Stoker  orders  two  drachms  of 
sulphate  of  soda  to  be  given  every  hour  until  the  bowels  move. 
Fowler  gives  half-ounce  doses  of  sulphate  of  magnesium  dis- 
solved in  Vichy  water ;  this  is  followed  by  drachm  doses  given 
hourly  until  the  bowels  act  thoroughly. 

In  the  employment  of  warm-water  injections  the  best 
method  to  adopt  is  to  introduce  a  soft  tube  well  up  the  rectum, 
and  allow  the  water  to  gravitate  slowly  into  the  bowel.  This 
should  be  repeated  several  times,  until  it  is  found  that  the 
return  of  fsecal  material  in  the  outflowing  fluid  indicates  that 
some  solvent  or  mechanical  effect  has  been  produced  upon  the 
contents  of  the  probably  loaded  colon. 

Movement  of  the  bowels  may  be  looked  upon  as  one  of  the 
best  indications  of  a  favourable  result. 

'  Brit.  Med.  Journ.  1895,  vol.  i.  p.  1193. 


APi'EXDICrnS— OPEllATK  )N  olS 


CHAPTER   LXIII 
APPENDICITIS  (continued),     operation,     other  diseases 

OF    THE    appendix 

Operation. — The  excision  of  the  appendix  will  be  found 
described  under  '  Appendicectomy  '  in  Chapter  LXVIII ;  but  it 
is  necessary  to  indicate  here  in  detail  some  of  the  numerous 
difficulties  and  complications  which  the  surgeon  may  have 
to  encounter  in  operation  upon  the  part,  whether  or  not  the 
appendix  is  removed. 

These  considerations  may  be  discussed  under  five  heads  : 
1.  Abscesses  ;  2.  Fistulse ;  3.  Adhesions  without  an  exudation  ; 
4.  Adhesions  with  an  exudation  ;  5.  Perforation  and  peri- 
tonitis. 

1.  Abscess. — In  cases  where  redness  and  oedema  of  the 
skin  over  the  iliac  region  indicate  the  approach  of  pus  to  the 
surface,  but  little  difficulty  is  encountered  in  reaching  it.  T'he 
skin  incision,  however,  should  not  be  larger  than  is  requisite 
for  the  free  evacuation  of  the  abscess.  A  too  free  mcision 
might  carry  the  opening  beyond  the  limits  of  the  adherent 
peritoneum,  and  so  endanger  the  general  peritoneal  cavity. 
Any  digital  examination  of  the  abscess  cavity  must  be  most 
cautiously  carried  out,  otherwise  limiting  adhesion  may  be 
inadvertently  broken  down  and  the  general  abdominal  cavity 
opened  into.  Nor  for  the  same  reason  should  any  violent 
irrigation  of  the  cavity  be  exercised.  Allis  ^  records  an  instance 
of  an  abscess  in  the  right  iliac  fossa  which  was  opened.  A 
surgeon  who  was  standing  by  requested  the  privilege  of  pass- 
ing his  finger  into  the  opening.  This  was  granted,  the  finger 
was  passed  deeply  into  the  cavity  and  swept  freely  round.  A 
rapidly  fatal  general  peritonitis  followed.  In  most  instances 
it  will  be  quite  sufficient  simply  to  open  the  abscess  at  its 
most  prominent  point,  put  in  a  large-sized  drainage  tube, 
and  so  disturb  the  part  as  little  as  possible.  "When  the 
abscess  presents  most  prominently  in  the  pelvis  towards 
the  rectum  it  should  be  opened  there,  as  advocated  and 
successfully  carried  out  in  three  cases  by  Allis. ^     No  attempt 

'  A7i?ials  of  Surgery,  1896,  vol.  xxiii.  p.  272. 

L   L 


514  THE   APPENDIX 

should  be  made  to  remove  the  appendix,  for  it  is  running 
needless  risk  in  a  class  of  cases  which  more  frequently  than 
not  recover  permanently. 

2.  Fistula. — Faecal  fistulse  sometimes  remain  after  the 
opening  or  bursting  of  an  abscess  either  through  the  ab- 
dominal parietes  or  into  the  rectum  or  bladder.  In  the 
former  case  the  fistula  may  be  due  to  a  fsecal  concretion,  the 
removal  of  which  by  forceps  leads  to  rapid  healing  of  the 
wound.  Where  no  such  source  of  irritation  exists,  the  fistula 
in  the  majority  of  cases  sooner  or  later  closes.  Its  undue 
persistence  may  depend  upon  a  perforated  appendix,  and  in 
such  cases  nothing  but  careful  dissection  of  the  region,  with 
removal  of  the  organ,  will  effect  a  closure  of  the  fistula. 

"Where  a  communication  exists  either  with  the  rectum  or 
the  bladder,  an  operation  to  reach  these  parts  will  be  neces- 
sary. It  will  probably  be  found  to  be  due  to  a  perforated 
appendix.  Eemoval  of  this,  with  closure  of  the  vesical  or 
rectal  aperture,  will  effect  a  cure.  In  a  case  recorded  by 
Hector  Cameron,^  where  a  communication  existed  between 
the  appendix  and  the  bladder,  the  patient  suffered  from 
symptoms  like  those  of  cystitis,  having  to  pass  urine  every 
half -hour.  The  abdomen  was  opened,  and  the  appendix  found 
attached  by  what  ought  to  have  been  its  free  extremity  to  the 
bladder.  It  was  ligatured  and  cut  out,  only  the  two  ends 
being  left  at  their  points  of  attachment.  The  patient  made 
a  perfect,  though  somewhat  tardy,  recovery. 

3.  Adhesions  loithoiit  exudation. — Every  degree  of  firmness 
may  be  found  in  the  adhesions  which  bind  the  appendix  to  the 
surrounding  parts.  In  the  worst  cases  the  intestines  about 
the  region  of  the  appendix  are  so  matted  together  that  the 
bowel  is  more  readily  torn  than  the  adhesions  separated.  In 
one  of  my  own  cases  I  was  forced  to  excise  two  or  three  inches 
of  the  ileum.  The  patient,  however,  made  a  perfect  and  un- 
interrupted recovery.  Treves  ^  in  two  of  his  cases  (Cases  XI. 
and  XII.)  pared  the  appendix  down  until  a  small  disc-shaped 
piece  was  alone  left  attached,  in  the  one  case  to  the  bowel, 
and  in  the  other  to  the  bladder.     Both  cases  recovered. 


•  Trans.  Path,  and  Clin.  Soc.  Glasgow,  1895,  vol.  v.  p.  123. 
2  Brit.  Med.  Journ.  1893,  vol.  i.  p.  837. 


APPENDICITIS— OPERATION  515 

4.  AiVacsions  witlt  exudation . — The  presence  of  an  exudation, 
purulent  or  otherwise,  adds  an  additional  complication  to 
the  existing  adhesions.  The  danger  in  these  cases  is  that  infec- 
tion of  the  peritoneum  may  be  caused  by  breaking  down 
adhesions  which  had  served  to  limit  and  cut  off  the  septic 
material  from  the  general  peritoneal  cavity.  If  the  cavity  be 
comparatively  small  it  may  be  thoroughly  wiped  dry  after  the 
removal  of  the  appendix,  and  then  freely  dusted  with  iodoform. 
In  one  such  case  I  closed  the  parietal  wound  after  this  treat- 
ment :  the  patient  recovered  without  an  untoward  symptom. 
If,  however,  the  cavity  be  larger  and  less  limited,  and  a  doubt 
remains  in  the  surgeon's  mind  as  to  his  having  perfectly 
removed  all  septic  matter,  the  cavity  should  be  carefully 
stuffed  with  strips  of  iodoform  gauze,  so  inserted  as  to  be 
easily  withdraw^n  in  the  course  of  forty-eight  hours  or  so. 

5.  Perforation  and  'peritonitis. — Treatment  in  these  cases 
demands  consideration  not  only  of  the  seat  of  the  disease,  but 
also  of  the  whole  peritoneal  cavity.  While  the  former  must 
be  dealt  with  according  to  the  conditions  found,  a  free  irriga- 
tion of  the  latter,  or  removal  of  the  septic  material  or  exudate 
by  sponge  cloths,  is  necessary.  If  it  is  found  impossible,  as  it 
most  likely  will  be,  to  deal  effectually  with  the  peritoneal  cavity 
through  the  lateral  incision,  a  median  one  must  be  made. 
The  question  whether  it  is  wise  to  irrigate  the  peritoneal  cavity 
in  all  cases  is  disputed  by  some  surgeons.  The  main  object 
in  view  is  the  removal  of  the  septic  material,  and  if  t bis  can 
be  effected  by  gently  wiping  the  parts,  it  is  probably  better 
than  flushing  them.  In  Lane's  case,  already  referred  to,  the 
peritoneal  cavity  was  not  w^ashed  out,  the  wound  was  closed, 
the  patient  kept  under  morphine,  and  nourishment  given 
per  rectum.  In  two  cases  of  recovery  mentioned  by  Barker,' 
flushing  was  employed,  no  drainage  tubes  were  introduced. 
In  McBurney's  successful  case  both  copious  irrigation  and 
drainage  were  used.  Demoulin  ^  in  his  successful  case  drained 
only,  and  sponged  away  any  exudate.  The  best  guide  to 
irrigation  or  non-irrigation  u  possibly  to  be  found  in  the 
nature  of  the  peritonitis.  If  this  is  of  the  adhesive  character 
irrigation  should   not   be  practised ;   if  on   the  other   hand 

'  Brit.  Med.  Joiirn.  1894,  vol.  i.  p.  355. 

^  Archives  Gendrales  de  Medecine,  1894,  vol.  i.  p.  712. 

L   L   2 


51  d  THE   APPENDIX 

there  is  a  quantity  of  purulent  material,  or  fe'al  extravasation, 
thorough  washing  out  and  drainage  should  be  employed. 

After  treatment  of  operation. — This  follows  upon  the  general 
lines  laid  down  for  all  operations  upon  the  intestinal  canal, 
with  the  only  possible  exception,  however,  of  an  early  endeavour 
to  get  some  action  of  the  bowels.  No  symptoms  are  more 
favourable  after  operation  than  a  fffical  evacuation  ;  while 
obstinate  constipation  may  prove  the  forerunner  of  general 
peritonitis.  Should  the  latter  symptom  be  accompanied  with 
gradual  rise  both  of  pulse  and  temperature  coupled  with  vomit- 
ing, the  surgeon  may  have  the  gravest  fears  regarding  the 
hopeful  prospect  of  the  case. 

The  aperients  given  are  those  already  indicated,  and  they 
may  be  administered  in  the  same  quantity  and  with  the  same 
frequency  (see  page  512).  Talamon  *  advocates  either  castor 
oil  or  calomel.  The  surgeon,  however,  will  often  be  guided 
best  by  what  the  patient's  stomach  seems  most  readily  to 
tolerate.     It  is  wise  to  avoid  violent  purgation. 

As  regards  diet,  only  small  quantities  of  warm  water  should 
be  given  during  the  first  twenty-four  hours.  Aft  r  this  a  little 
peptonised  milk  can  be  administered,  and  a  gradual  increase 
in  the  quantity  and  strength  of  the  food  henceforth  proceeded 
with. 

Should  symptoms  of  peritonitis  become  manifest,  the 
usual  measures  must  be  adopted.  Whether  or  not  the 
surgeon  feels  justified  in  reopening  the  abdomen  and  cleans- 
ing the  peritoneal  cavity  must  be  determined  by  the  general 
condition  of  the  patient.  So  far  I  have  not  come  across  tbe 
record  of  any  case  where  such  treatment  has  been  followed 
with  success. 

Other  diseases  of  the  appendix. — With  the  exception  of 
inflammation  there  are  but  few  other  diseases  M'hich  affect 
primarily  and  exclusively  the  appendix.  Tumours  of  both 
a  malignant  and  innocent  character  are  occasionally,  though 
very  rarely,  met  with.  Stimson  ^  records  having  removed 
an  appendix  in  a  state  of  cancerous  degeneration.  It  was 
four  inches  in  length  and  nearly  an  inch  thick.  The  greatly 
thickened  mucous  membrane  projected  in  the  form  of  a  ring 

'  Appendicite  et  Pdrityphlite,  1892,  p.  211. 
'-'  Annals  of  Surgery,  1896,  vol.  xxiii.  p.  186. 


PLATE    XXV. 


Fi.sj.  64— .Cystic  Vermiform  Appendix.    (K./.CW.,  GUn.) 


DISEASES  517 

into  the  lumen  of  the  cascum.  Kelynack/  as  the  result  of  a 
very  searching  inquiry,  found  only  two  references  to  primary 
disease  of  the  part.  One  of  these  was  Leichtenstern's  report 
of  three  cases  of  cancer  of  the  appendix,  about  which,  how- 
ever, from  want  of  a  full  report,  there  remains  doubt  as  to 
the  primary  origin  of  the  disease;  and  the  other,  Draper's 
case  of  supposed  colloid  carcinoma.  The  appendix  may  of 
course  become  involved  secondarily  by  extension  from  neigh- 
bouring parts,  but  in  this  the  organ  presents  features  in 
common  with  other  regions  of  the  intestinal  canal. 

In  making  the  post  mortem  of  a  patient  who  had  died  of 
chronic  Bright's  disease,  I  ^  removed  an  appendix  which  had 
undergone  cystic  degeneration.  The  organ  was  quite  normal 
for  its  proximal  two  inches,  but  the  distal  portion,  measuring 
another  iwo  inches,  was  dilated  into  an  egg-shaped  tumour  (see 
Plate  XXV,  fig.  64),  On  opening  this  latter,  it  was  found  to 
be  distended  with  a  clear  gelatinous  substance  which  could 
be  turned  out  en  masse,  leaving  a  smooth,  slightly  sacculated 
wall.  Coats  ^  has  reported  and  figured  a  similar  condition, 
the  only  one  he  has  met  with  in  his  extensive  pathological 
experience.  In  the  Eoyal  Infirmary  of  Glasgow  there  is  a 
remarkable  specimen  of  apparently  a  similar  disease.  The 
appendix  has  been  transformed  into  a  bulky  cyst.  It  measures 
five  and  a  quarter  inches  in  its  long  diameter,  and  one  and 
a  quarter  to  two  inches  in  its  short  diameter.  In  shape  it 
resembles  an  elongated  cylinder,  and  was  filled  with  a  thick 
mucous  material.  The  patient  died  of  renal  disease,  and 
apparently  had  not  during  life  any  symptoms  connected  with 
the  cystic  appendix.* 

The  attention  which  has  been  directed  to  the  appendix  by 
pathologists  in  recent  years  may  result  in  the  organ  being 
found  diseased  much  more  frequently  than  previously  supposed. 
Lewis  Sutherland,  of  the  Western  Infirmary,  Glasgow^  reports 
having  met  with  two  instances  of  cj^stic  disease  resembling 
those  narrated  above,  while  making  post  mortems. 

'  Pathology  of  the  Vermiform  Ai:ii)enclix,  p.  139. 

2  Trans.  Path,  and  Clin.  Soc.  Glasgozo,  1892,  vol.  iv.  p.  111. 

*  Manual  of  Pathology,  3rd  edit.  p.  876. 

*  Museum  Catalogne,  series  vi.  p.  92. 


518 


THE    INTESTINES 


CHAPTEE   LXIV 

OPERATIONS  UPON  THE  SMALL  AND  LARGE  INTESTINE 


I.  ENTEROTOMY 
II.  ENTEROSTOMY 

III,  ENTERECTOMY 

IV.  ENTERO-ENTEROSTOMY 
V.    ENTEROPLASTY 

YI.    COLOTOMY 


VII.    COLOSTOMY 
VIII.    COLECTOMY 
IX.    COLOPEXY 
X.    ARTIFICIAL  ANUS 
XI.    APPENDICECTOMY 
XII.    OTHER  OPERATIONS 


Operations  upon  the  bowel  are  numerous,  but  still  more 
numerous  are  the  methods  employed  in  performing  them. 
It  is  impossible  within  a  comparatively  limited  space  to  do 
more  than  describe  those  operations,  and  the  methods  of 
executing  them,  which  may  be  said  to  have  attained  to  some 
degree  of  general  recognition.  Of  many  methods  it  may  be 
truly  said  that  they  receive  little  more  application  than  that 
exercised  by  the  originator.  An  operation  and  its  mode  of 
execution  in  order  to  pass  beyond  the  exclusive  practice  of 
its  author,  must  in  the  first  place  possess  all  the  elements 
of  simplicity  in  its  application,  and  in  the  second  be  certain 
in  effecting  the  end  required.  Many  an  operation  upon  the 
bowel  has  to  be  performed  at  short  notice,  under  unfavour- 
able surroundings,  with  limited  assistance,  and  often  by 
not  very  experienced  operators.  Any  method  therefore  which 
fails  to  give  the  surgeon  the  necessary  requirements  under 
all  circumstances  must  be  considered  unsatisfactory,  and 
cannot  be  expected  to  commend  itself  to  more  than  a  very 
limited  circle. 

Where  various  methods  exist  for  performing  one  particular 
operation,  and  where  the  merits  of  one  oiier  no  very  striking 
advantage  over  the  merits  of  another,  the  surgeon  would  do 
well  to  select  one,  and  be  prepared  to  practise  that  efficiently 
when  occasion  requires.  Unless  the  operator  be  one  whose 
practice  is  large  in  the  department  of  gastro-intestinal  surgery, 
to  try  one  method  after  another  is  only  too  likely  to  end  in 
never  succeeding  with  any. 

In  the  list  of  operations  which  follow,  I  have  endeavoured 
to  simplify  their  description  by  adopting  some  sort  of  a  classi- 
fication.    It  is  not  easy,  however,  to  prevent  overlapping;  nor 


OPERATIONS— NOMENCLATURE  619 

is  it  easy  to  assign  a  definition  in  certain  cases  where  contem- 
porary literature  applies  to  a  word  more  than  one  meaning. 
Thus  the  word  'colotomy'  ought  to  be  limited  to  merely 
incising  the  colon  for  the  extraction  of  a  foreign  body  &c.,  just 
in  the  same  sense  as  the  word  '  gastrotomy  '  is  used  in  regard  to 
the  stomach.  It  is,  however,  often  applied  to  what  should  be 
more  strictly  termed  '  colostomy.'  It  is  frequently,  too,  used 
to  express  the  formation  of  an  artificial  anus.  Similarly 
'  enterotomy '  is  used  for  '  enterostomy,'  the  term  signifying 
the  establishment  of  a  faecal  fistula  in  cases  of  acute  obstruction. 
As,  however,  we  now  have  the  term  '  enterostomy '  for  this 
operation, '  enterotomy '  should  be  limited  to  a  similar  usage  as 
that  of  '  gastrotomy,'  that  is  to  say,  the  simple  incision  of  the 
bowel,  with  its  immediate  suture.  The  word  '  enterorrhaphy  ' 
lacks  also  in  aptness  and  correctness  of  application.  If  it  is  to 
signify  in  the  case  of  the  bowel  what  it  implies  in  the  case  of  the 
stomach,  it  should  mean  the  suturing  together  of  a  fold  in  the 
wall  of  a  dilated  intestine.  It  is,  however,  used  to  indicate 
suturing  together  the  cut  walls  of  the  bowel.  As  nearly  all 
operations  involve  more  or  less  suturing  of  the  edges  of  a  bowel 
wound,  the  term  becomes  practically  synonymous  with  tlie  word 
'  suture,'  and  for  simplicity  of  nomenclature  it  would  be  better 
to  abandon  it.  Its  ambiguity  is  further  increased  by  the  fact 
that  it  is  sometimes  used  for  methods  of  uniting  the  bowel  other 
than  those  by  suture.  Another  somewhat  ambiguous  word  is 
*  colostomy.'  Here,  again,  if  it  is  to  rank  in  similarity  of  ex- 
planation with  '  gastrostomy '  and  '  oesophagostomy,'  the  term 
should  signify  strictly  the  stitching  of  the  colon  to  the  parietal 
wound,  and  the  formation  of  an  opening  in  the  bowel;  in 
other  words,  the  production  of  a  fsecal  fistula.  It  is,  however, 
frequently  used  for  the  operation  of  producing  an  artificial 
anus,  where  the  entire,  and  not  the  partial,  contents  of  the 
bowel  are  allowed  to  escape  externally. 

The  terms  '  ileostomy,'  '  colostomy,'  and  '  sigmoidostomy  ' 
are  in  one  sense  misnomers.  Their  extension  in  usage  to  the 
formation  of  f£ecal  fistulae  is  strangely  out  of  keeping  with  the 
true  meaning  of  the  words.  In  the  cases  of  the  oesophagus, 
stomach,  duodenum,  and  jejunum,  the  affix  '  stomy '  {stoma, 
a  mouth)  has  a  correct  application ;  but  considered  from  the 
same  point  of  view,  it  becomes  peculiarly  inappropriate  to 


620 


THE   INTESTINES 


operations  which  have  for  their  object,  not  the  j)ro(iuction  of 
an  orifice  (mouth)  of  entrance,  but  one  of  exit  (anus).  The 
terms,  however,  have  this  advantage,  that  they  signify  opera- 
tions which  in  all  points  of  their  performance  are  similar  to 
those  in  which  the  affix  has  its  strictly  correct  meaning  from 
the  functional  aspect  of  the  question. 

Again,  there  is  much  confusion  in  the  use  of  the  terms 
intended  to  imply  the  junction  or  union  of  one  part  of  the 
bowel  to  another.  If  the  union  of  the  stomach  to  the  jejunum 
be  termed  *  gastro-jejunostomy,'  then  the  union  of  the  jejunum 
to  the  ileum  should  be  '  jejuno-ileostomy ; '  of  the  ileum  to  the 
colon,  'ileo-colostomy.'  It  is  not,  however,  infrequent  to  find 
the  operation  spoken  of  in  the  inverse  way — thus,  '  ileo-jejuno- 
stomy.'  Further  confusion  exists  in  the  fact  that  these  terms 
are  sometimes  used  for  two  totally  distinct  operations,  as  for 
instance  the  lateral  approximations  and  fistulous  connection 
between  two  coils  of  intestine ;  and  the  entire  implantation 
of  the  transverse  section  of  one  portion  of  bowel  into  an 
orifice  in  the  lateral  wall  of  another. 

If  authors  would  use  terms  which  have  the  same  relative 
significance  in  the  oesophagus,  stomach,  and  intestines,  where 
comparisons  can  be  drawn,  the  whole  nomenclature  of  the 
subject  would  be  greatly  simplified,  and  some  degree  of  per- 
spicuity would  exist  where  at  present  there  is  often  much 
confusion. 

The  following  list  may  be  taken  to  fairly  represent  the 
more  or  less  recognised  operations  upon  the  small  and  large 
intestine — excluding  those  of  the  duodenum,  which  have 
already  been  given,  and  those  of  the  rectum,  which  will  be 
described  later. 


I.  Enterotomy 
II.  Enterostomy 

III.  Enterectoniy 


\a.  Jejunotomy. 
|&.  Ileotomy. 

a.  Jejmiostomy. 

b.  Ileostomy. 


[a.  Entero-anastomosis 
i.6.  Artificial  amis  (enteric) 


,1.  End-to-end  ana- 
stomosis. 

2.  Lateral  anasto- 
mosis or  ap- 
proximation. 

3.  Lateral  implan- 
'     tation. 


OrERATIONS  521 

Mctliods  of  uniting  howcJ, 

A.  By  suture. 

,     ^.       1         \a.  Czerny-Lembert  (WcJlfler's  modification  of). 

1.  Circular    -'       -r^.  ,     "^, 

( 0.  Ijisaop  s. 

2.  Abbe's  method. 

3.  Maunsell's  method. 

4.  Halsted's  method. 

B.  B}'  '  plates  '  made  of  decalcified  bones,  &c. 

C.  By  '  tubes  '        „      „  „  „        „ 

D.  By  '  bobbins.' 

E.  By  metal  buttons. 

F.  By  rings. 

G.  Other  special  methods. 

j  a.  Jejuno-jejunostomy. 
IV.  Entero-enterostomy         ]  b.  Jejuno-ileostomy. 
(short-circuiting),    j  c    Ileo-ileostomy. 
\d.  Ileo-colostoniy, 


V.  Enteroplasty. 
VI.  Colotomy. 

VII.  Colostomy. 


'  a.  Lumbar,  right  and  left. 
b.  Inguinal  (sigmoidostomy" 
VIII.  Colectomy-,  ceecectomy,   ( a.  Entero-anastomosis. 
sigmoidectomy.  [b.  Artificial  anus. 

IX.  Colopex3\ 

a.  Caecal. 

b.  Eight  colonic. 

c.  Left  colonic. 

d.  Sigmoid. 
\e.  Enteric. 


X.  Artificial  anus. 


XL  Appendicectomy. 
XII.  Other  operations — Gastro-enterostomy. 

Cholecystenterostomy. 

Uretero-enterostomy. 

Cystenterostomy. 

In  describing  the  various  operations  upon  the  bowel  it  is 
not  intended  to  preface  each  operation  witli  the  steps  required 
to  open  the  abdomen  except  in  so  far  as  they  may  be  of  a 
special  nature  in  certain  cases.  The  line  of  incision  will  be 
given,  and  anything  particular  regarding  the  division  or 
separation  of  the  deeper  structures  ;  but  such  points  as  the 
preliminary  cleansing  of  the  skin,  the  arrangement  of  aseptic 
cloths  or  towels,  the  proper  securing  of  all  bleeding  points,  and 
other  such  general  considerations  as  concern  the  proper  pre- 
paration of  the  patient,  and  the  place  of  operation,  all  of  which 
have  been  frequently  dealt  with  before,  will  not  be  repeated. 


622  THE    INTESTINES 

I.  Enterotomy. — The  operation  is  performed  for  the  removal 
of  obstructive  agents,  such  as  gall  stones  &c.,  from  the  interior 
of  the  small  intestine.  The  terms  jejunotomy  and  ileotomy 
imply  that  the  operation  is  performed  either  upon  the  jejunum 
or  the  ileum. 

Operation. — The  abdomen  is  opened  in  the  median  line, 
usually  below  the  umbilicus. 

The  loop  of  intestine  containing  the  body  to  be  removed  is 
withdrawn  from  the  abdomen,  and  carefully  protected  there 
with  suitably  disposed  cloths  to  prevent  any  contamination 
of  the  abdominal  cavity  when  the  bowel  is  opened. 

An  assistant  squeezes  out  of  the  intestinal  loop  with  his 
thumb  and  forefinger  such  contents  as  can  be  so  removed, 
and  then  clamps  each  portion  of  the  bowel  on  the  proximal 
and  distal  sides  of  the  part  to  be  opened,  by  constricting  with 
the  thumb  and  forefinger  of  each  hand. 

By  an  incision  of  requisite  length  the  surgeon  opens  the 
intestinal  canal  in  the  long  axis  of  the  bowel,  at  the  part 
of  the  wall  most  distant  from  the  mesenteric  attachment. 
The  obstructing  agent  is  extracted,  any  bleeding  points  secured, 
and  the  edges  of  the  wound  tucked  in  and  united  by  a  con- 
tinuous Lembert  suture.  Care  must  be  taken  to  see  that  the 
mucous  membrane  is  well  involuted.  After  cleansing  the 
part,  the  loop  is  returned  to  the  abdomen  and  the  parietal 
wound  closed. 

The  term  '  enterotomy  '  has  been  applied  to  Nelaton's 
operation,  see  below — enterostomy. 

II.  Enterostomy. — This  operation  is  performed  in  the  upper 
part  of  the  small  intestine — jejunostomy — for  obstruction 
above,  while  it  is  performed  in  the  lower  part — ileostomy — for 
obstruction  below.  In  the  former  case  it  is  for  the  object 
of  supplying  nourishment  to  the  patient,  while  in  the  latter  it 
is  to  relieve  the  bowel  of  its  obstructed  fsecal  contents. 

The  general  term  '  enterostomy  '  may  be  suitably  applied  to 
Nelaton's  operation,  which  is  thus  performed. 

'  The  seat  of  the  operation  is  the  iliac  or  inguinal  region, 
preference  being  given  to  the  right  side.  An  incision  is  made 
through  the  abdominal  parietes  parallel  to  and  a  little  above 
Poupart's  ligament  and  to  the  outer  side  of  the  epigastric 
artery.     The  skin  incision  is  recommended  to  be  about  7  cm.  in 


OPERATIONS— JEJITNOSTOMY  5i'3 

length.  The  deep  mcision  whereby  the  peritoneum  is  opened 
being  about  4  cm.  in  length.  The  first  distended  coil  of 
bowel  that  presents  itself  is  gently  seized  and  drawn  into  the 
wound.  If  the  operation  be  performed  upon  the  right  side  it 
is  found  that  the  segment  of  intestine  opened  is  nearly  always 
the  terminal  part  of  the  ileum.  The  gut  is  then  fixed  to  the 
wound  by  a  double  line  of  sutures  which  transfix  the  intestinal 
walls.  An  opening  is  finally  made  into  the  bowel  between 
the  two  lines  of  suture,  and  the  operation  is  completed' 
(Treves). 

Jejunostomy. — The  operation  is  performed  for  extensive 
disease  of  the  stomach,  when  gastro-enterostomy  is  not 
possible. 

Operaiion. — An  incision  is  made  in  the  middle  line,  between 
the  ensiform  cartilage  and  the  umbihcus.  The  index  finger  is 
inserted  and  a  loop  of  the  jejunum  hooked  up.  To- ensure 
that  the  portion  of  the  bowel  secured  is  the  highest  part  that 
can  be  easily  withdrawn,  it  should  be  traced  upwards  till  the 
origin  of  the  duodenum  is  recognised. 

The  bowel  can  then  be  stitched  to  the  margin  of  the 
parietal  wound,  and  left  for  four  or  five  days  to  contract 
adhesions  before  being  opened. 

Jessetfs  modification.^ — The  required  loop  having  been 
drawn  through  the  abdominal  wound,  the  author  thus  describes 
the  further  steps  of  his  operation :  '  I  then  pass  a  long 
straight  needle  armed  with  silkworm  or  chromic  gut  beneath 
the  serous  and  muscular  coats  of  the  intestine  in  a  longi- 
tudinal direction  for  from  one  to  two  inches,  first  on  one  side 
of  the  convex  surface,  then  on  the  other  ;  these  two  sutures 
run  parallel  to  each  other  and  are  about  an  inch  apart.  I 
next  pass  two  more  sutures  armed  with  needles  across  from 
the  points  where  the  longitudinal  threads  escape.  I  thus  have 
a  parallelogram  enclosed  between  my  four  sutures ;  each  of 
these  is  now  passed  through  the  abdominal  parietes  about  half 
an  inch  on  each  side  of  its  cut  edge  and  through  a  decalcified 
bone  plate  with  an  opening  in  the  centre  '  (as  shown  in  figs.  22 
and  23,  seep.  237). 

'  The  threads  are  next  held  in  clamp  forceps  while  the 
parietal  w^ound  is  closed  in  the  ordinary  way.     The  threads 

'  Surgical  Diseases  of  the  Stomach  and  Intestines,  p.  61. 


524 


THE   INTESTINES 


are  then  tied  firmly  over  the  bone  plates,  first  the  lateral 
threads  and  then  the  end  threads  (as  shown  in  fig.  23)  ;  and 
finally  a  portion  of  the  intestine  is  drawn  up  through  the 
opening  in  the  bone  plate  and  transfixed  with  a  hare-lip  pin 
which  rests  on  the  bone  plate  (fig.  23).  The  abdominal 
wound  is  closed  by  a  couple  of  silkworm-gut  sutures  at  each 
end.  The  wound  is  dressed  in  the  ordinary  way  ;  and  on  the 
fifth  day,  or  earlier  if  necessary,  a  small  opening  is  made  with 
a  tenotomy  knife,  and  a  winged  gum- elastic  catheter  intro- 
duced and  the  patient  fed  by  means  of  this.'  This  same  method 
of  operating  is  adopted  by  Jessett  for  gastrostomy. 

MaydVs  modification} — An  incision  is  made  about  10  ctm. 
long  in  the  middle  line,  between  the  umbilicus  and  the  en  si- 
form  cartilage. 

The  jejunum  is  sought  for  about  1  ctm.  from  the  plica- 
duodeno-jejunalis,  emptied   at  this  spot  of  its  contents,  and 

surrounded  by  two  strips  of  iodoform 
gauze  which  are  passed  through  the 
mesentery  and  tied.  The  bowel  is 
then  cut  transversely  across  between 
the  two  strips.  An  incision  about  3 
ctm.  long  is  made  in  the  convex  side 
of  the  distal  segment,  and  into  this 
the  orifice  of  the  proximal  segment 
is  stitched  (see  fig.  65).  The  orifice 
of  the  distal  segment  is  brought  out 
at  the  abdominal  wound,  and  secured 
there.  This  latter  opening  is  reduced 
so  as  to  form  an  orifice  of  only  2  ctm. 
in  breadth. 

The  object  of  this  operation,  like 
that  of  Albert's  which  follows,  is  to 
procure  a  means  of  preventing  the  escape  of  the  bile,  pancreatic 
and  gastric  secretions  through  the  intestinal  orifice. 

Alhert's  modification} — The  incision  through  the  parietes 
is  the  same  as  that  of  Maydl. 

A  loop  of  jejunum  is  brought  out  through  the  parietal 
wound,  which  is  for  the  greater  part  temporarily  closed.     At 

'    Wiener  rued.  Wochenschrifl,  1892,  No.  20,  p.  785. 
2  Ibid.  1894,  No.  2,  p.  57. 


Fig.  65. — Diageam  of  Maydl's 
Operation  of  Jejunostomy 

a,  orifice  of  jejunum  stitched  to  parie- 
tal wound  ;  b,  lateral  implantation 
of  upper  segment  into  the  side  of 
the  lower 


0PERATI0X,S--ILE(3ST()MV 


the  base  of  the  loop  a  lateral  anastomosis  Is  made  between 

the  proximal  and  distal  j^arts. 

Parallel   to    the  first    sldn    incision    and    4    ctm.    above 

it    another    incision    is  made,    and  a  strip    of   skin    2    ctm. 

long   raised.     Beneath  this  the  loop  is   passed  and  secured 

(see  fig.  6Q)   (as  in  Franks's  method  for  gastrostomy).     The 

lax    portion    of  the  loop  with   its 

anastomotic  portion  is  now  dropped 

into    the    abdominal    cavity,    and 

the    first    parietal    wound    closed. 

On   the    fourth    day    an    opening 

is  made  by   means   of  Paquelin's 

cautery  into  the  loop,  and  nourish- 
ment administered. 

Ileostomy. — This  operation  con- 
sists in  opening  the  lowest  part  of 

the  ileum  for  extensive  obstructive 

disease  in  the  region  of  the  caecum 

and  ileo-cgecal  valve. 

The  operation  is  thus  described 
by  Thomas  Bryant,^  who  success- 
fully employed  it  in  a  case. 

'  An  incision  about  2  or  2^ 
inches  long  was  made  in  the 
direction  of  the  right  semilunar  line,  with  its  centre  corre- 
sponding to  a  line  drawn  across  the  abdomen  from  one 
anterior  superior  spinous  process  of  the  ilium  to  the  other.' 

After  the  peritoneal  cavity  was  opened  '  the  right  index 
finger  was  introduced,  which,  having  pushed  aside  the  coil  of 
intestine  which  presented  itself,  came  down  at  once  upon  the 
cascum.'  With  this  guide  the  finger  hooked  up  the  ileum 
where  it  was  about  to  join  the  caecum.  It  was  then  stitched 
to  the  parietal  peritoneum  by  sutures  passing  through  the 
serous  and  muscular  coats  of  the  bowel.  The  angles  of  the 
wound  were  brought  together  by  sutures,  and  two  silk  loops 
were  introduced  into  the  walls  of  the  bowel  to  serve  as  guides 
to  the  second  part  of  the  operation.  On  the  third  day  of  the 
operation  the  intestine  was  opened  by  an  incision  about  a 
quarter  of  an  inch  long,  to  be  enlarged  if  necessary. 


Fig.  66. — Diagbam  of  Albert's 
Operation  of  Jejunostomy 

a,  apes  of  loop  of  jejunum  drawn  out 
beneath  strip  of  skin  between  tlie 
first  incision,  6,  anrl  the  second  in- 
cision ;  a,  first  incision  closed  alter 
making  lateral  anastomosis  at  c 
(jejuno  jejunostomy)  and  returning 
the  bowel  into  the  abdomen 


Lancet,  1S91,  vol.  i.  p.  1. 


526  THE    INTESTINES 

CHAPTER   LXV 

OPERATIONS  {continued)  :  iii.  enteeectomy 

III.  Enterectomy. — The  operation  implies  excision  of  any 
part  of  the  small  intestine  for  tumour,  disease,  or  injury. 
Except  in  the  case  of  gangrene  from  strangulated  hernia,  the 
part  of  the  bowel  to  be  removed  is  withdrawn  from  the 
abdomen  through  an  incision  made  in  the  median  line  either 
above  or  below  the  umbilicus. 

Operation. — The  involved  loop  of  gut  is  retained  by  the 
hands  of  an  assistant  outside  the  parietal  incision.  The 
abdominal  cavity  is  protected  by  properl}'  disposed  sponges 
or  cloths. 

The  contents  of  that  portion  of  the  bowel  which  is  to  be 
included  between  the  clamps  is  carefully  squeezed  out,  and 
the  intestine  clamped  at  a  convenient  distance  from  each 
margin  of  the  proposed  line  of  section. 

Methods  of  clamjmig. — Various  instruments,  complicated 
and  simple,  have  been  devised  for  preventing  the  escajDe  of 
the  faeces  after  excision  of  the  segment. 

A  simple  method  is  to  pass  pieces  of  indiarubber  tubing 
through  the  mesentery  at  the  required  spots,  and  either 
knot  them  or  secure  them  by  means  of  pairs  of  forcipressure 
forceps  (fig.  29,  see  p.  250). 

Another  equally  simple  method,  and  one  which  I  am  in 
the  habit  of  making  use  of,  is  to  slip  pieces  of  indiarubber 
tubing  over  the  blades  of  two  pairs  of  ordinary  dissecting 
forceps.  One  blade  of  each  pair  is  thrust  through  the 
mesentery  at  the  requisite  spot,  and  then  closed  by  slipping 
another  piece  of  tubing  over  the  approximated  blades.  The 
clamping  can  thus  be  rapidly  performed,  the  bowel  is  not 
puckered  as  in  the  previous  method,  and  the  forceps  can 
be  prepared  beforehand,  and  kept  with  the  tubing  in  an 
antiseptic  solution  ready  for  use  (see  figs.  30-33,  pp.  250, 
251).  Among  special  instruments,  those  by  Makins,  Lane, 
Treves,  and  Bishop  may  be  mentioned.  In  those  devised 
by  the  latter  two  surgeons,  the  clamps  are  connected  by 
rods  which  admit  of  their  being  approximated  when  the 
requisite  portion  of  bowel  has  been  removed. 


OrER  ATIONS  -ENTERECTOM  Y 


.'527 


Excision. — The  bowel  being  clamped,  it  is  divided  at  a 
convenient  distance  from  the  clamps  either  by  knife  or 
scissors.  The  mesentery  when  reached  may  either  be  divided 
along  the  attachment  to  the  bowel  or  a  wedge-shaped 
piece  excised.  In  both  instances  the  vessels  must  be  caught 
up  with  catch  forceps  and  ligatured.  The  removal  or  not 
of  a  wedge-shaped  piece  of  mesentery  depends  upon  the 
length  of  the  portion  of  bowel  excised  and  the  ultimate  steps 
of  the  operation.  For  the  completion  of  the  operation  one  of 
two  steps  must  be  taken — either  the  continuity  of  the  canal  is 
to  be  re-established,  or  it  is  to  be  permanently  or  temporarily 
interrupted  by  the  formation  of  an  artificial  anus. 

Entero-anastomosis  usually  consists  in  the  re-estabhsh- 
ment  of  the  continuity  of  the  canal  after  the  operation  of 
enterectomy,  or,  better,  it  completes  the  performance  of  this 


Fig.  67 — End-io-end  Anastomosis 


Fig.  G8. — Lateral  Anastomosis 
OR  Approximation 


Fig.  69. — Lateral  Implantation 


Figs.  67-69. — Diagrammatic   Eepresentation   of   Entero-anastomosis 
AETER  Enterectomy 


operation  ;  it  is,  however,  also  used  to  signify  the  union  and 
communication  of  two  segments  of  the  gut  without  excision. 
There  are  three  methods  by  which  this  end  can  be  effected. 

1.  End-to-end  anastomosis. — By  this  method  the  canal 
above  becomes  directly  continuous  with  the  canal  below 
(fig.  67),  the  free  edge  of  one  transverse  section  of  the  bowel 
being  united  to  the  free  edge  of  the  other. 

2.  Lateral  anastomosis  or  approximation. — By  this  method 


528  THE   INTESTINES 

the  two  ends  of  the  divided  bowel  are  placed  side  by  side  for  a 
distance  of  some  four,  live,  or  more  inches.  The  cut  extremities 
are  closed,  but  the  continuity  of  the  canal  is  established  by  lateral 
openings  in  the  sides  of  the  coapted  bowel  surfaces  (tig.  68). 

3.  Lateral  implantatiun. — By  this  method  the  transverse 
section  of  one  end  is  closed,  while  the  orifice  of  the  other  end 
is  stitched  with  an  opening  made  in  the  wall  of  the  occluded 
segment  (fig.  69). 

Whichever  of  the  above  methods  is  selected,  the  next  con- 
sideration is  the  way  in  which  the  union  of  the  parts  is  to  be 
effected. 

Methods  of  uniting  bowel. — Of  all  the  departments  of  in- 
testinal surgery  none  has  exercised  such  an  amount  of 
ingenuity  on  the  part  of  surgeons  as  that  which  concerns  the 
efficient  union  of  an  orifice  in  one  part  of  the  bowel  with  an 
opening  in  another.  Since  the  time  of  Jobert  in  1822,  but 
more  particularly  within  recent  years,  '  new  methods '  of 
intestinal  suturing  have  been  constantly  promulgated.  How 
much  real  advance  is  being  made  by  these  later  discoveries  it 
is  hardly  possible  to  say ;  but  one  thing  is  certain,  that  many 
a  so-called  new  method  is  very  little  more  than  a  repetition 
or  slight  modification  of  an  earlier  one.  I  have  myself 
seen  a  method  proposed  as  new  and  original  which  had, 
on  three  earlier  and  different  occasions,  and  by  three 
separate  surgeons  also,  been  propounded  as  a  '  new  method.' 
Nothing  short  of  a  treatise  itself  would  suffice  to  give  the 
history  and  describe  all  the  numerous  methods  of  suture  and 
union  of  bowel  which  have  been  projected  within  the  last 
half-century.  Many  doubtless  have  been  practised  by  none 
other  than  the  originator.  Some,  however,  have  extended  to 
a  wider  field  of  application ;  and  it  is  only  to  these  that  I 
venture  to  draw  attention.  Doubtless  I  have  failed  to 
describe  other  methods  as  worthy  and  as  useful  as  those  here 
given,  but  I  feel  I  shall  quite  sufficiently  serve  my  purpose 
and  that  of  the  reader  by  not  further  lengthening  my  list. 

A.  Union  hy  suture. — By  this  method  is  understood  the 
union  of  the  bowel  surfaces  without  the  aid  of  any  mechanical 
contrivances,  and  only  by  thread,  gut,  silk,  &c.  Three  ways 
of  effecting  this  may  be  instanced. 

1.  The  circular. — By  tiiis  means  the  bowel  orifices  are 
end  to  end.     It  may  be  efficiently  done  by  {a)  the  Czerny- 


OrERATIONS— SUTURE 


529 


Lembert  suture  or  this  method  modified  by  "VVolfler,  or  (h) 
by  Bishop's  suture. 

a.  The  Czerny-Lembert  consists  in  passing  two  separate 
rows  of  interrupted  sutures  around  the  margin  of  the  cut 
edges  from  without ;  while  Wolfler's  modification  of  the  same 
consists  in  placing  the  first  row  ('Czernys')  from  within. 
Thus  in  the  former  method  the  inner  row  of  stitches  takes  up 


Fig.  70. — Lembekt  Suture 
The  studies  p.TSS  tliroughthe  sero-muscular  tunics  of  tlie  bowel  svall 


-a 


Fig.  71. — Czeeny-Lemeert  Suture 

Tlie  first  series  of  stitclies  pass  through  the  edges  of  the  sere  musculiir 
tunics  and  are  tied  externally.    The  second  series  are  Lembei'ts 


Fig.    72. — Wolflee's  Modification  of  the  Czeent-Lembeet 

The  stitches  are  tlie  same,  with  the  exception  that  the  first 
series  are  tied  internally  instead  of  externally. 


DiAGEAMMATIC    EePEESENTATION    OF    UnION    OF    BoWEL    EnDS 
BY     CiRCULAE    SUTUEE 


Figs.  70-72 

a,  the  serous  coat ;  b,  the  muscular  coat ;  c,  the  mucous  membrane 


and  unites  the  free  edges  of  the  serous  and  muscular  coats, 
the  knots  when  tied  lying  without  the  canal  (fig.  71)  ;  in  the 
latter  the  same  parts  are  secured,  but  the  knots  when  tied  lie 

M  M 


530 


THE   INTESTINES 


within  the  canal  (fig.  72).  In  both  methods  an  external  row 
of  interrupted  Leml  ert  stitches  encircles  the  inner  series. 
The  mesentery  is  united  well  up  to  the  bowel,  and  great  care 
should  be  given  to  the  coaptation  of  the  mesenteric  edges 
at  their  attachments  to  the  bowel. 

b.  Bishop's  suture.^ — '  The  two  divided  ends  of  intestine 
being  brought  together  so  that  their  mesenteric  borders  lie  in 
an  exact  plane,  a  fine  round  needle  (No.  11),  armed  with  a 
long  double  silk  thread,  is  passed  from  the  mucous  surface  of 
one,  through  the  entire  walls  of  both,  to  the  mucous  surface  of 
the  other.  The  needle,  and  with  it  the  double  thread,  is  drawn 
until  about  five  inches  of  the  thread  are  left  on  the  side  from 
which  it  has  been  passed.  The  needle  is  then  again  passed 
in  the  reversed  direction  at  a  distance  of  2  or  3  mm. 
from  the  first  puncture,  and  the  threads  drawn  through  until 
a  double  loop  is  left,  having  also  a  length  of  five  inches 
(fig.  73).      One  of  the  loops  is  cut  through,    the  other   is 


Fig;  73. — Bishop's  Sutuee 

drawn  up  and  knotted  with  a  reef-knot  on  the  side  started 
from.  When  the  knot  is  made  the  ends  are  cut  off  close. 
Thus  one  loop  has  been  formed  uniting  the  two  bowel  walls 
by  their  seroils  surface.  On  the  far  side  of  the  loop  a  long 
single  thread  is  left,  passing  through  the  same  opening  as 
that  passed  through  by  the  distal  limb  of  the  loop.  (This 
thread  is  required  later  in  finishing  the  last  loop,  and  is  use- 
ful all  through  the  operation  as  a  means  whereby  the  bowel 
may  be  kept  in  position  at  the  abdominal  wound.)  On  the 
near  side  of  the  loop  is  another  thread  attached  to  the  needle, 

'  Trans.  Med.-Chir.  Soc.  Loncl.  1887,  vol.  Ixx.  p.  347. 


OPERATIONS— SUTURE 


531 


and  also  passing  through  the  same  opening  as  that  which 
holds  the  near  limb  of  the  loop.  Ee versing  the  needle  and 
carrying  it  again  through  the  walls  in  the  same  direction  as 
at  first,  another  loop  is  made,  which  in  its  turn  is  knotted  on 
the  opposite  side  to  the  first  knot ;  and  hy  a  repetition  of  the 
same  acts  a  series  of  loops  is  formed  all  around  the  lumen 
of  the  intestine,  each  individual  loop  surrounding  its  own 
moiety  of  both  walls  passing  through  the  same  openings  as 
its  fellows  on  either  side,  but  perfectly  independent  of  them, 
lying  transversely  to  the  line  of  union  and  parallel  to  the 
plane  of  the  intestine,  not  so  tightly  tied  as  at  once  to  stran- 
gulate the  tissue  enclosed,  but  certain,  as  it  ulcerates  out,  to 
carry  with  it  that  portion  of  the  valvular  ring.  The  knots 
and  nearly  the  whole  of  the  loops  are,  moreover,  inside  the 
re-formed  canal.' 


Fig.  74. — Suturing  Intestine  in 
Apposition  before  opening 

a,  first  line  of  Lembert  sutures ;  b, 
seco-.ia  parallel  line  of  Lemberts  ; 
c,  line  of  incision  into  bowel 

Figs.  74  and  75. 


Fig.  75. — Suture  of  Edges  of 
Openings  prior  to  the  com- 
pletion OF  the  two  lines 
OF  Lemberts 

-Abbe's  Suture 


2.  Abbe's  method  of   suture.^ — This   method   is   intended 
for  cases  of  lateral  anastomosis  where  enterectomy  has  been 


'  Medical  Press  and  Circular,  1892,  vol.  ii.  p.  188. 


M    M    2 


532  THE   INTESTINES 

performed.  The  open  ends  of  the  bowel  are  first  closed  by 
invagination  of  the  serous  surface  and  the  insertion  of  a  con- 
tinuous Lembert  suture.  The  lateral  surfaces  are  then  applied 
to  each  other  so  that  about  five  inches  of  one  extremity  extends 
alongside  the  other  for  an  equal  distance.  A  continuous 
Lembert  stitch  is  passed  for  nearly  the  entire  length  of  the 
applied  surfaces,  and- upon  this  and  parallel  to  it  a  second 
continuous  suture  is  passed  (fig.  74).  Both  needles  are  left 
threaded  at  the  end  of  the  continuous  series.  The  bowel  is 
now  opened  by  an  incision  four  inches  long,  situated  a  quarter 
of  an  inch  from  the  sutures.  '  Another  silk  suture  is  now 
started  at  one  corner  of  the  openings,  and  unites  by  a  quick 
overhand  the  two  cut  edges.  The  needle  pierces  both  mucous 
and  serous  coats,  and  thus  secures  the  bleeding  vessels,  from 
which  the  clamps  (previously  applied  to  stop  haemorrhage)  are 
removed  as  the  needle  reaches  them.  This  suturing  is  then 
continued  round  each  free  edge  in  turn  (fig.  75),  and  all  bleed- 
ing points  are  thus  secured  more  quickly  than  by  ligature. 
The  serous  surfaces  around  these  button-holes  are  then  rapidly 
secured  by  a  continuation  of  the  sutures  first  applied,  the 
same  threads  being  used,  the  one  nearest  the  cut  edge  first. 
The  united  parts  are  again  rinsed  with  water  and  dropped 
into  the  abdomen.' 

3.  MaunselVs  method  of  suturing^ — This  method  is  em- 
ployed for  end-to-end  union  after  enterectomy.  The  portion 
of  intestine  having  been  removed,  both  ends  of  the  bowel  are 
brought  together  by  two  temporary  sutures  passed  through 
ah  the  coats  of  the  intestine.  The  long  ends  of  these  sutures 
are  left  uncut.  One  suture  is  placed  at  the  mesenteric  attach- 
ment of  the  gut,  and  the  other  exactly  opposite  (fig.  76).  The 
coats  of  the  intestine  are  pinched  up  transversely  (fig-  76,  h), 
opposite  to  the  mesenteric  attachment,  between  the  finger  and 
the  thumb,  and  divided  with  a  tenotomy  knife  or  a  pair  of 
scissors.  This  opening  should  be  made  about  an  inch  from 
the  severed  end  of  the  larger  segment  of  bowel.  Its  length 
depends  upon  the  size  of  the  gut  to  be  invaginated.  The 
long  ends  of  the  two  temporary  ligatures  are  attached  to  a 
probe  which  is  passed  through  the  bowel  and  brought  out  at  the 

'  Abstracted  from  the  International  Jownal  of  the  Medical  Sciences,  1892, 
N.S.  vol.  ciii.  p.  245. 


OPERATIONS— SUTURE 


533 


incision  (fig.  77).  When  pulled  upon  tbey  invaginate  the  bowel 
and  bring  out  the  divided  extremities  at  the  incision  (fig.  78). 
While  an  assistant  holds  the  ends  of  the  temporary  sutures,  the 


Fig.  76. 


Fig.  78. 


Fig.  79. 
Figs.  76-79. — Maunsell's  Sutuke 

Fig.  76  shows  the  two  segments  united  at  the  mesenteric  and  opposite  borders  of  tlie  gut  by  the  two 

temporary  sutures  a  ;  at  6  the  bowel  is  pinclied  up  transversely  prior  to  opening  b}' transfixion. 

Fig.  77  shows  the  two  tempnrarj'  stitches  tucked  in,  and  brought  out  at  the  newly  made  orifice  a. 

Fig.  78. —The  temporary  stitches  have  been  drawni  upon,  the  bowel  invaginated  and  brought  out  of 

the  orifice  a  ;  the  needle  b  is  seen  passing  through  both  walls  of  the  gut,  carrying  with  it  the 

thread  for  tying  the  margins. 
Fig.  79  shows  the  operation  completed.    The  orifice  a  is  closed  with  a  continuous  Lembert  suture, 

and  two,  three,  or  more  sutures  are  inserted  into  the  mesentery. 

surgeon  passes  a  long,  fine,  straight  needle,  armed  with  a  stout 
horsehair  or  very  fine  silkworm  gut,  through  both  sides  of  the 
bowel,  taking  a  good  grip  (quarter  of  an  inch)  of  all  the  coats 
(fig.  78,  6).    The  suture  is  then  hooked  up  from  the  centre  of 


534 


THE   INTESTINES 


the  invaginated  gut,  divided,  and  tied  on  both  sides.  In  this 
way  twenty  sutures  can  be  placed  rapidly  in  position  with  ten 
passages  of  the  needle.     The  temporary  sutures  are  now  cut  off 


Fig.  80 Fiest  Stage 


iG.  81.—  Second  Stage 


Fig.  82.— Thikd  Stage  Fig.  83.— Fourth  Stage 

Figs.  80-83. — Halsted's  Method  of  Suturing 


OPERATIONS-SUTURE  635 

short,  and  the  sutured  ends  of  the  bowel  dusted  with  iodoform. 
The  bowei  is  then  jDuUed  back.  The  l(;ngitudinal  sht  in  the 
gut  is  well  turned  in  and  closed  with  a  continuous  suture 
(tig.  79)  and  redusted  with  iodoform.  One  or  two  sutures 
should  be  put  in  the  mesentery. 

This  operation  is  also  proposed  for  irreducible  cases  of 
intussusception.  The  longitudinal  incision  is  used  for  the 
withdrawal  of  the  intussusceptum  and  the  proper  union  of 
the  parts  about  the  neck  of  the  invagination.  Quite  similar 
methods  for  the  radical  treatment  of  intussusception  have 
been  devised  by  A.  E,  Barker,  Jessett,  and  Bier  respectively. 

4.  HalstecVs  method  of  suture.^ — This  method  resembles 
Abbe's  in  being  suited  for  lateral  approximation.  It  differs, 
however,  in  the  kind  of  suture  used.  After  the  two  bowel 
surfaces  are  placed  together,  a  series  of  interrupted  quilt  or 
square  stitches  are  inserted  (fig.  80).  'Six  square  or  quilt 
stitches  are  taken  in  a  straight  row  near  the  mesenteric 
borders  of  the  selected  portion  of  the  intestine  and  tied.  At 
each  end  of  this  posterior  row  of  stitches,  and  nearer  the  con- 
vex border  of  the  intestine,  two  lateral  square  stitches  are 
applied  (fig.  81)  and  tied  ;  a  little  beyond  the  convex  border 
the  eight  or  nine  square  stitches  which  constitute  the  anterior 
row  and  complete  the  oval  are  applied,  but  not  immediately 
tied.  They  are  first  drawn  aside  (fig.  82)  to  make  room  for 
the  knife  or  scissors  with  which  the  intestines  are  then 
opened.  Finally  the  sutures  of  the  anterior  row  are  tied ' 
(fig.  83). 

B.  Union  by  x>lates. — Senn's  method  ^  with  decalcified 
bone  plates  takes  precedence  of  all  others.  These  plates, 
when  used  in  purely  intestinal  surgery,  are  suited  best  for 
lateral  approximation. 

For  a  description  of  the  preparation  of  the  plates,  see 
p.  253  (gastro-enterostomy). 

The  method  of  threading  the  plates  is  best  understood  by 
a  reference  to  the  accompanying  figures.  Two  fine  sewing 
needles  are  threaded  each  with  a  piece  of  aseptic  silk  twenty- 
four  inches  in  length ;  these  are  tied  together  as  shown  in 
fig.  84.     By  means  of  a  fine  hook  a  loop  of  the  thread  is 

'  From  Jessett  on  Surgical  Diseases  of  the  Stomach  and  Intestines,  p.  238. 
^  Joitrnal  of  the  American  Medical  Sciences,  1892,  vol.  xiv.   p.  845. 


636 


THE   INTESTINES 


Fig.  84.  Fig.  85. 

Figs.  84  and  85.— Senn's  Method  of  Threading  Decalcified  Bone  Plates 

Fig.  84  shows  silk  tliread  with  ncerlles  attacTied,  and  knotted  ;  fig.  85  shows  first  step 
in  threading  plate  by  means  of  hook 


OPEIIATJONS— SUTURE  537 

drawn  through  one  of  the  perforations  in  the  hone  plate,  as 
shown  in  fig.  85.  A  similar  loop  is  in  the  same  way  drawn 
through  each  of  the  other  perforations,  and  then  a  thread  run 
through  each  of  these  double  loops,  and  secured  as  shown  in 
fig.  86.  When  the  knotted  ends  and  the  needles  are  drawn 
taut  the  plate  is  ready  for  use,  as  shown  in  fig.  34  (see  p.  254). 
Littlewood '  suggests  the  following  modification  of  Senn's 
plates.  A  tube  of  decalcified  hone  is  fixed  into  the  aperture 
of  one  of  the  plates,  and  made  to  accurately  fit  into  the  aper- 


FiG.  86. — Sbnn's  Method  of  Threading  DECAiiCiFiED  Bone  Plates 

Pig.  86  shows  loops  drawn  through  the  perforations,  ami  thread  passed  througli  the  loops 

ture  of  the  other.  By  this  method  the  two  plates  are  held 
together,  and  the  two  parts  of  the  intestinal  wall  between 
them  brought  evenly  into  contact  with  each  other. 

When  a  portion  of  bowel  has  been  excised,  the  two  open 
extremities  are  invaginated  and  closed  by  a  continuous 
Lembert  suture.     As  in  the  case  of  Abbe's  method,  the  two 

'  Lancet,  1892,  vol.  i.  p.  865, 


538  THE    INTESTINES 

segments  are  placed  side  by  side ;  and  to  give  extra  security 
after  the  plates  are  inserted  and  tied,  a  continuous  suture 
(fig,  87,  a)  is  run  between  the  two  surfaces.  The  openings 
in  the  apposed  surfaces  of  the  bowel  are  then  made,  and  the 


Fig.  87.—  Senn's  Method  of  Lateral  Anastomosis 

Fig.  87  shows  two  poitions  of  bowel  united  togftlier  by  a  continuous  Lembert  suture  c.  The 
plates  have  been  inserted  through  the  lateral  longitudinal  incisions  ;  the  knotted  ends  6  are 
seen  passing  out  at  the  estiemities  of  the  inte  tinal  orifices  while  the  lateral  sutures  c,  with 
needles  attached,  are  passing  thiough  the  margins  of  the  bowel  wall 

plates  inserted.  The  assistant  then  approximates  the  two 
openings  while  the  surgeon  ties  first  the  lower  lateral  threads, 
second  the  end  ones,  and  lastly  the  upper  lateral. 

Plates  made  of  raw  hide  have  been  used  by  Kobinson,^ 
and  potato  plates  by  Dawbarn.^ 

C.  Union  by  tubes. — This  method  is  employed  for  end- 
to-end  union,  and  its  object  is  to  effect  an  easier  and  more 
exact  coaptation  of  the  bowel  margins,  as  well  as  to  maintain 
a  patent  and  free  channel  between  the  two  segments.  Tubes 
of  various  materials  have  been  used,  but  those  which  have 
met  with  most  favour  are  made  either  of  decalcified  bone  or 
of  indiarubber. 

PauVs  method  with  decalcified  bone  tubes.^ — After  removal 
of  the  piece  of  bowel,  the  bone  tube  (fig.  88)  is  inserted  into 
the  upper  end  and  sewn  with  a  fine  suture,  great  care  being 
taken  to  attach  the  mesenteric  border  securely.  Next  the 
traction  thread  is  passed  through  the  wall  of  the  lower  seg- 
ment (fig.  89),  the  cut  ends  of  the  bowel  sewn  together  with 
another  fine  suture,  and  the  wound  in  the  mesentery  united. 
The  assistant  then  firmly  holds  the  traction  thread  while  the 

'  Neiu  York  Med.  Journ.  1890,  vol.  Hi.  p.  429. 

^  Annals  of  Surgery,  1893,  vol.  xvii.  p.  147. 

^  Abstracted  from  the  Livcri^ool  Mcd.-Chir.  Journ.  1892,  vol.  xii.  p..  477. 


Ori':RAT[()NS— SUTURE 


5yj 


Burgeon  invaginatcs  the  bowel  for  about  half  an  inch,  fixing 
it  in  this  position  with  four  small  Lembert  sutures  (fig.  90). 
The  traction  thread  is  drawn  tight,  cut  off  short,  and  the 
ends  allowed  to  drop  into  the  bowel.     '  When  invaginating, 


Fig. 


Fig.  89. 


Fig.  90. 

Figs.  88-90.— Paul's  Method  of  Sdtxjee  with  Bone  Tubes 

Fig.  88  shows  the  decaloifiea  boue  tube  threaded  and  with  needle  attached  ;  fig.  89  shows  tlie  tube 
stitcliedin  tlie  bowel  and  the  traction  threads  passed  tlirough  the  loop  to  be  approximated  ; 
fig.  9U  shows  the  operation  completed,  with  a  lew  interrupted  Lembert  sutures  inserted  at  tlie 
external  line  of  union 

an  error  must  be  guarded  against.  The  invagination  is 
most  easily  produced  by  allowing  it  to  commence  about  half 
an  inch  or  so  below  the  tube.  This  means  that  the  cut  end 
will  be  barely  covered  by  it,  whilst  the  lumen  of  the  bowel 
will  be  considerably  blocked  and  the  operation  consequently 
most  imperfectly  performed.  It  must  be  made  to  commence 
immediately  below  the  tube  by  drawing  the  very  first  part 
of  the  lower  segment  upwards  with  the  tips  of  the  fingers,  and 
care  must  be  exercised  to  observe  that  the  mesenteric  side  of 
the  bowel  is  as  thoroughly  covered  by  the  invagination  as  the 
other  side.' 

liohinson's  method  with  indiaruhher  tuhe.^ — A  rubber  tube 
of  from  three  to  six  inches  in  length  and  of  suitable  cahbre  is 
stitched  into  the  proximal  segment.  The  serous  surface  of 
the  segment  is  scarified  for  an  inch  from  the  cut  edge.     The 

'  Annals  of  Surgery,  1891,  vol.  xiii.  p.  86. 


540 


THE   INTESTINES 


mucous  membrane  of  the  distal  segment  is  dissected  off 
for  half  an  inch  with  a  curved  pair  of  scissors,  and  the 
freshened  surface  well  curetted,  so  that  all  the  intestinal 
glands  are  destroyed.  The  proximal  segment  is  then  pushed 
into  the  distal  bowel  lumen  '  as  one  joint  of  stove-pipe  is 
pushed  into  another,'  and  the  distal  drawn  over  and  sutured 
in  position.     The  sutures  are  passed  completely  through  the 


Fig.  91. — Robinson's  Method  of  iSuTUiiE  with  Indiakubber  Tube 

circumferential  margin  of  the  distal  bowel,  and  through  the 
peritoneum  and    muscular   coat   of  the   proximal    segment. 
Jessett  has  modified  the  method  by  using  in  place  of  rubber  . 
tubes,  decalcified  bone  tubes. 

The  method  is  unsuited  for  cases  where  much  disparity  of 
size  exists  between  the  two  segments. 

D.   U7iio7i  hy  decalcified  hone  bobbins. — This  method,  pro- 

posed    by    Mayo   Eobson,^    is   for 

either  end-to- end  union  or  lateral 
approximation. 

The  author  in  his  earlier  opera- 
tions used  two  continuous  sutures, 
a  marginal  and  a  serous.  More 
recently  he  has  not  '  hesitated  to 
employ  one  continuous  stitch  to 
unite  the  whole  thickness  of  the 
gut  where  time  was  an  object  in  the 
case.'  In  employing  a  single  suture 
for  end-to-end  union,  a  silk  thread 
eighteen  inches  in  length  is  threaded 
upon  a  curved  sewing  needle ;  the 
posterior  margins  of  the  two  visceral 
openings  (in  cases  of  enterectomy)  are  united  from  right  to  left, 
the  suture  including  mucous  membrane,  the  tail  of  the  suture 
being  left  long  on  the  right  side  and  kept  threaded  on  the 
left.  The  bobbin  (fig.  92)  is  now  inserted,  one  end  being  in 
each  segment  of  the  bowel.     The  suture  is  then  proceeded 

'  Brit.  Med.  Journ.  1893,  vol.  i.  p.  689  ;  also  1895,  vol.  ii.  p.  963. 


Fig.  92. — Eobson's  DECAiiCiFiED 
Bone  Bobbin.     (Full  size) 


OPERATIONS— SUTURE 


541 


with  around  the  front  until  the  tail  of  the  suture  is  reached. 
The  two  ends  are  then  drawn  tight,  tied,  and  cut  off  short, 
and  the  operation  comi^leted. 

When  a  second  continuous  suture  is  used  in  cases  of  lateral 
approximation  this  constitutes  the  serous  suture,  and  is 
applied  about  half  an  inch  from  the  place  where  the  viscera 
are  to  be  opened.  The  posterior  is  passed  between  the  con- 
tiguous serous  surfaces  first,  both  ends  being  left  long,  so 
that  after  the  viscera  are  opened  and  the  bobbin  inserted,  the 
suture  can  be  continued  around.  When  drawn  tight  it  com- 
pletely shuts  in  the  marginal  or  mucous  suture. 

The  bobbin  shown  in  the  figure  is  the  second  largest  in 
size.     Three  other  smaller  sizes  are  in  use. 

E.  Union  hy  metal  buttons. — By  this  method  either  end-to- 
end  or  lateral  union  can  be  effected.  It  owes  its  origin  to 
Murphy,^  by  whose  name  the  buttons  are  generally  known. 


Fig.  93.  Fig.  94.  Fig.  95. 

Figs.  93-95. — Muephy's  Method  of  Union  with  Metal  Button 

Fig.  93  shows  manner  of  inserting  tlireail  in  eud-to-end  union  :  a,  double  turn  of  tlie  thread 
tlirougli  the  mesentery ;  6,  peritoneum  ;  o,  mesentery  ;  d,  ends  of  thread.  Figs.  94:  and  95 
show  running  thread  before  and  after  incision  of  bowel  in  lateral  anastomosis 

Four  sizes  of  these  buttons  are  in  use— No.  1,  which  is  |  inch 
in  diameter  ;  No.  2,  ||  inch  ;  No.  3,  -ff  inch  ;  and  No.  4, 1  inch. 
End-to-end,  side-to-side,  and  end-to-side  of  the  small  intestine 
should  be  made  with  button  No.  3.     End-to-end  and  side-to- 


Lanccf,  1895,  vol.  i.  p.  1012. 


542  THE   INTESTINES 

side  of  the  large  intestine  should  be  made  with  No.  4.  (See 
figs.  35  and  36,  p.  256.) 

In  effecting  end-to-end  union  the  suture  is  made  to  pass 
around  the  cut  margin  of  each  end  of  the  bowel,  as  shown  in 
fig.  93.  The  double  turn  through  the  mesentery  tends  to 
ensure  efficient  occlusion  of  that  part  of  the  coapted  bowel 
margins.  The  two  halves  of  the  button  are  then  inserted, 
and  the  '  puckering-string '  is  drawn  tight.  The  union  is 
completed  by  pressing  the  two  portions  of  the  button  to- 
gether. Care  must  be  taken  to  include  the  free  edges  of  the 
bowel  between  the  two  halves.  The  compressed  tissue  sloughs 
and  comes  away  with  the  button,  and  an  opening  as  large  as 
the  button  remains. 

In  effecting  lateral  union  much  the  same  process  is  gone 
through.  After  the  '  puckering-string '  has  been  passed 
(fig.  94)  and  incisions  of  sufficient  length  made  in  the  long 
axis  of  the  bowel,  one  half  of  the  button  is  placed  in  each 
viscus,  the  string  drawn  up  and  fastened,  and  the  halves  of  the 
button  pressed  together. 

'  When  returning  the  bowels  to  the  abdomen,  they  should 
be  placed  in  parallel  lines,  especially  at  the  seat  of  approxima- 
tion, to  prevent  sharp  curves  and  obstruction.' 

F.  Union  by  rings. — This  method  is  intended  for  end-to- 
end  union.  Eings  made  of  catgut  have  been  used  by  Abbe  ; 
and  segmented  rubber  rings  have  been  proposed  by  Brokaw. 
Both  these  kinds  of  rings  have  already  been  described  in  the 
operation  of  gastro-enterostomy,  and  need  not  therefore  be 
further  referred  to  here.     (See  p.  256.) 

G.  Other  methods  of  union. — Various  forms  of  clamps  have 
been  invented  with  the  object  of  holding  the  parts  in  apposition 
until  union  has  been  effected.  One  of  these,  devised  by 
Morison,^  has  fixed  to  one  blade  a  tube  which,  when  the  clamp 
is  inserted  and  the  bowel  tied  around,  admits  of  the  escape  of 
faeces.  Another,  introduced  by  Grant,^  carries  between  the 
two  clamping  blades  a  knife,  by  which  it  is  possible  to  make 
an  incision  through  the  coapted  surfaces. 

As   lending  some  assistance  to  the  surgeon  to  make    a 


'  Brit.  Med.  Journ.  1893,  vol.  ii.  p.  1047. 
^  Annals  of  Siirgcry,  1896,  vol.  xxiii.  p.  38. 


OPERATIONS— ENTERO-ENTEROSTOMY  543 

selection  from  these  various  methods,  Edmunds  and  Ballance  ' 
reported  to  the  Medico-Cbirurgical  Society  of  London  the 
results  of  numerous  experiments  upon  dogs  to  ascertain  the 
best  method  of  uniting  bowel  to  bowel  or  bowel  to  stomach. 
In  the  case  of  the  intestine,  they  found  that  for  lateral  ana- 
stomosis Halsted's  operation  was  best ;  and  for  end-to-end 
union  Maunsell's  operation  wa3  the  best,  when  conditions 
would  admit  of  its  performance. 


CHAPTER   LXVI 

OPERATIONS  {continued):  iv.  entero-enterostomy ;  v.  entero- 

PLASTY  ;  VI.  COLOTOMY  ;  VII.  COLOSTOMY  ;  VIII.  COLECTOMY  ; 
IX.  COLOPEXY 

IV.  Entero-enterostomy  (short-circuiting). — This  operation 
is  performed  when  it  is  impossible  to  remove  the  diseased 
portion  of  the  bowel.  It  consists  in  the  lateral  approximation 
of  two  segments  and  the  formation  of  a  fistulous  communi- 
cation. When  the  operation  consists  in  uniting  one  portion 
of  the  jejunum  to  another,  it  is  called  '  jejuno-jejunostomy  ; ' 
when  the  jejunum  to  the  ileum,  it  is  called  '  jejuno-ileostomy  ; ' 
when  one  part  of  the  ileum  to  another,  '  ileo-ileostomy ; '  and 
when  the  ileum  to  the  colon,  '  ileo- colostomy.'  These  same 
terms  are  frequently  applied  for  what  has  already  been  de- 
scribed as  lateral  implantation  ;  but  when  so  employed,  the 
homology  is  lost  between  these  operations  and  gastro-entero- 
stomy.  To  effect  this  method  of  anastomosis,  either  sutures 
such  as  Abbe's  may  be  employed,  or  some  of  the  mechanical 
methods  by  'plates,'  'buttons,'  or  'bobbins.'  Eeference  to 
these  methods,  given  above,  will  sufficiently  indicate  the  mode 
of  operation  in  cases  suited  for  entero-enterostomy. 

V.  Enteroplasty. — This  operation  is  for  the  treatment  of 
simple  stricture  of  the  small  intestine,  and  is  intended  to  be 
adopted  in  place  of  enterectomy  for  these  cases.  The  opera- 
tion resembles  in  every  respect  that  of  the  Heineke-Mikulicz 
operation  of  pyloroplasty  (see  p.  265),  It  appears  to  have 
been  first  successfully  employed  by  Pean,-  who  adopted  the 

'  Brit.  Med.  Jonrn.  1896,  vol.  i.  p.  1200. 

^  Bulletin  dc  VAcademie  de  Medccinc,  1890,  p.  856. 


544  THE   INTESTINES 

metliod  for  a  stricture  of  the  ileo-csecal  valve.  It  has  more 
recently  been  practised  by  Allingham.^  The  operation  con- 
sists in  dividing  the  stricture,  and  then  uniting  the  edges  of 
the  wound  transversely,  so  that  the  centre  of  the  incision  comes 
to  be  at  the  ends. 

VI.  Colotomy.— This  operation,  like  that  of  enterotomy, 
gastrotomy,  and  oesophagotomy,  consists  in  an  incision  into 
the  canal  for  the  extraction  of  any  foreign  or  obstructing 
material  and  the  immediate  closure  of  the  wound. 

The  incision  is  made  into  any  part  of  the  large  intestine, 
immediately  over  the  seat  of  the  object.  The  incision  is  in 
the  long  axis  of  the  bowel,  and  at  its  convex  border — that  is 
to  sa}'',  equidistant  on  each  side  from  the  mesentery.  After 
removal  of  the  object,  the  wound  is  closed  by  a  continuous 
Lembert  suture,  due  care  being  exercised  to  properly  involute 
the  cut  margins. 

The  term  '  colotomy '  was  always  and  is  now  frequently 
used  for  the  operation  which  is  often  and  much  more  aj)pro- 
priately  designated  '  colostomy.' 

VII.  Colostomy. — The  object  of  this  operation  is  to  form  a 
frecal  fistula  in  the  large  bowel,  although  the  practical  result 
may,  in  some  cases,  be  an  artificial  anus.  When  made  in  the 
lumbar  region,  it  constitutes,  according  to  the  side,  a  right 
or  left  lumbar  colostomy  ;  when  in  the  inguinal  region,  an 
inguinal  or  iliac  colostomy  ;  and  when  the  sigmoid  flexure  is 
opened,  sigmoidostomy. 

The  operation  is  usually  performed  for  some  obstruc- 
tion below,  either  in  the  colon  or  in  the  rectum  ;  and  also 
in  certain  diseases  of  the  colon  and  rectum,  where  it  is 
desirable  to  irrigate  and  medicate  the  segment  of  the  bowel 
below  the  artificial  orifice. 

Lumbar  colostomy. — When  performed  in  the  right  loin,  this 
operation  is  known  as  Amussat's,  and  the  skin  incision  is 
transverse  ;  when  in  the  left  loin,  it  is  called  Callisen's,  and  the 
skin  incision  is  vertical.  Bryant,  who  is  one  of  the  strongest 
advocates  for  this  operation,  prefers  an  oblique  incision  in 
whichever  loin  the  bowel  is  to  be  opened.  The  steps  of  the 
operation  are  thus  described  by  this  surgeon  :  ^ 

'  Lmicet,  1891,  vol.  i.  p.  1551. 

^  The  Practice  of  Surgery,  2ncl  edit.  vol.  i.  p.  633. 


OPEllATFONS  -  LUMBAR    COLOSTOM  Y  r,4r, 

'  The  operation  can  be  performed  as  follows,  on  the  left 
loin  :  The  patient  is  to  l)e   placed  on  his  right  side  with   a 
pillow  beneath  the  loin,  in  order  to  arch  somewhat   the  left 
flank,  and  turned  two-thirds  over  on  his  face;  the  outer  bor- 
der of  the  quadratus  lumborum  muscle  can  then  be  made  out, 
as  this  muscle  is  the  surgeon's  main  guide.     Its  outer  border 
with  the  descending  colon  is  to  be  foand  half  an  inch  posterior 
to  the  centre  of  the  crest  of  the  ihum,  the  centre  being  the 
point  midway  between  the   anterior  superior   and  posterior 
superior   spinous  processes.  .  .  .  An  incision  is  then  to  be 
made  four  or  five  inches  long,  beginning  an  inch  and  a  half 
to  the  left  of  the  spine  below  the  last  rib,  and  passing  down- 
wards and  forwards  parallel  with  the  crest  of  the  ilium  ;  the 
line  of  the  incision  should  pass  obliquely  across  the  external 
border  of  the  quadrat  as  lumborum  muscle  about  its  centre,  so 
as  to  take  the  same  direction  as  the  nerves  which  traverse  this 
part.     By   this    incision   the   integuments   and  muscles  and 
fascia  are  divided,  and  the  outer  border  of  the  quadratus  muscle 
exposed.     The  abdominal  muscles  can  be  divided  to  give  room, 
and  this  had  better  be  done  upon  a  director.     All  vessels  are 
now  to  be  secured.     The  transversalis  fascia  will  next  come 
into  view,  and  beneath  this  will  be  the  colon,  a  layer  of  fat 
sometimes    intervening.     The   fascia   is    to   be  opened   with 
caution,  for  in  the  loose  fat  and  cellular  tissue  the  colon  is  to 
be  found;   when  distended,  the  bowel  comes  at  once  under 
the  eye  on  dividing  the  fascia,  but  when  empty   some  little 
trouble  may  be  experienced  in  hooking  it  up  with  the  finger. 
It  can  always  be  found  in  front  of  the  lower  border  of  the 
kidney.     This  organ  should  consequently  be  sought,  as  it  is 
the  only  certain  guide  to  che  bowel.  .  .  .  When  the  bowel  has 
been  caught,  it  should  be  partially  rolled  forward  in  order  to 
expose  its  posterior  surface,  for  if  this  be  not  done,  there  is  a 
risk  of  the  surgeon  wounding  the   peritoneum   where  it    is 
reflectsd  from  its  anterior  surface  on  to  the  abdominal  wall. 

*  The  bowel  having  been  drawn  up  to  the  wound  is  then 
to  be  secured  to  the  integument  and  not  to  the  muscles,  by 
the  passage  of  a  ligature  introduced  through  one  margin  of 
the  wound,  then  through  the  bowel,  and  lastly  through  the 
other  margin.  The  bowel  can  then  be  opened  by  a  longitu- 
dinal incision  about  three-quarters  of  an  inch  long  over  the 

N  N 


546  THE   INTESTINES 

ligature  that  has  traversed  its  canal ;  the  centre  of  the  hgature 
is  then  to  he  drawn  out  and  divided,  the  two  halves  of  the 
ligature  fixing  the  two  sides  of  the  divided  intestine  firmly  to 
the  margins  of  the  wound  ;  and  two  or  four  more  stitches  may 
then  be  introduced  to  make  the  artificial  anus  secure.' 

Inguinal  colostomy.  Sigmoidostomy. — To  open  the  colon  in 
either  the  right  or  left  inguinal  region,  an  incision  from-  two 
to  three  inches  in  length  is  commenced  just  external  to  the 
line  of  the  deep  epigastric  (marked  by  a  line  drawn  from  the 
femoral  artery  to  the  umbilicus),  and  upwards  and  outwards, 
parallel  to  Poupart's  ligament  and  about  an  inch  or  an  inch 
and  a  half  above  it. 

After  opening  the  peritoneal  cavity,  the  forefinger  is  in- 
serted to  bring  up  the  colon  to  the  wound.  That  the  bowel 
thus  secured  is  the  large  intestine,  is  Lnown  by  the  presence 
of  longitudinal  bands  and  appendices  epiploicse,  and  by  its  sac- 
culated appearance.  To  maintain  the  bowel  in  position  while 
it  is  being  stitched,  two  temporary  traction  sutures  may  be 
inserted,  one  towards  each  end ;  these  pass  through  all  the 
coats,  and  can  be  left  in  as  guides  for  the  subsequent  opening 
of  the  gut.  By  a  continuous  suture,  or  several  interrupted 
ones,  the  margins  of  the  parietal  wound  are  stitched  to  the 
sero-muscular  coat  of  the  bowel.  If  there  is  no  urgency  in  the 
case  nothing  further  is  done,  and  the  wound  is  left  for  four  or 
five  days,  in  order  to  get  a  firm  union  between  the  bowel  and 
the  parietes.  An  opening  is  then  made  with  scissors  or  a 
knife,  the  two  traction  strings  being  pulled  upon  to  act  as 
guides  for  the  line  of  the  incision. 

In  this  operation  no  attempt  is  made  to  form  a  '  spur,' 
nor  to  check  in  any  way  the  passage  of  faecal  matter  from 
the  part  of  the  canal  above  the  opening  into  that  below  it. 
This  latter  object,  when  required,  is  effected  by  the  formation 
of  an  artificial  anus,  and  differs  from  any  form  of  colostomy 
which  merely  seeks  to  establish  a  ffecal  fistula. 

VIII.  Colectomy. — This  operation  implies  the  excision  of 
some  portion  of  the  large  intestine  for  disease  or  injury. 
When  the  caecum  is  removed  the  operation  is  termed 
'  caecectomy/  and  when  it  is  the  sigmoid  flexure  it  is  called 
*  sigmoidectomy.' 

Operation. — The  skin   incision  is  made   according  to  the 


OPER  ATIUNS— COLECTOM  V  547 

supposed  seat  of  the  disease  ;  when  located  in  the  more 
frequent  locahties,  as  the  caecum  or  the  sigmoid  flexure,  the 
incision  through  the  parietes  is  the  same  as  that  given  above 
for  inguinal  colostomy  :  when  in  the  ascending  or  def^cending 
colon,  along  the  outer  border  of  the  rectus  muscle :  and  when 
in  the  transverse  colon,  in  the  median  line  above  the  um- 
bilicus. 

After  opening  the  peritoneal  cavity  sufficiently  freely  to 
admit  of  the  affected  portion  being  well  drawn  out  of  the 
parietal  wound,  the  bowel  is  clamped  and  the  operation  pro- 
ceeded with  in  the  same  way  as  has  already  been  described  in 
the  case  of  the  operation  of  enterectomy.      (See  p.  527.) 

The  next  stage,  after  removal  of  the  affected  portion,  consists 
in  one  of  two  procedures — either  some  form  of  union  is  effected, 
with  re-establishment  of  the  continuity  of  the  canal,  or  an 
artificial  anus  is  formed.  If  it  is  proposed  to  unite  the  ends  of 
the  bowel,  then  one  of  the  methods  already  described  must  be 
adopted.  As  a  practical  guide  to  the  surgeon  in  deciding  what 
course  he  should  pursue,  the  following  advice  given  by  Paul 
may  be  repeated  here.  '  When  the  patient  is  in  good  con- 
dition, the  abdomen  not  distended,  the  tumour  small,  and 
the  proximal  end  of  the  bowel  not  greatly  hypertrophied,  im- 
mediate approximation  by  Murphy's  button  maybe  attempted. 
But  when  the  opposite  of  these  conditions  prevails,  the  ends 
of  the  bowel  should  be  brought  out.' 

Although  Paul  specially  advocates  the  use  of  Murphy's 
button,  success  has  followed  the  employment  of  suture, 
Eobson's  bobbins,  and  some  of  the  other  mechanical  measures. 
In  eases  where  it  is  deemed  advisable  to  make  an  artificial 
anus  the  following  method  of  performing  colectomy,  as 
advocated  by  Paul,  may  be  employed  : 

Paul's  operation.^ — 'Make  a  sufficiently  free  incision  over 
the  site  of  the  tumour.  Having  cleared  away  any  adhesions, 
ligature  the  mesentery  with  the  help  of  an  aneurysm  needle, 
and  divide  it  sufficiently  to  free  the  bowel  well  beyond  the 
growth  on  each  side.  Let  the  loop  of  bowel  containing  the 
growth  or  stricture  hang  out  of  the  abdomen,  and  sew  together 
the  mesentery  and  the  adjacent  sides  of  the  two  ends  '  (as 
shown  in  fig.  96) .     *  The  stump  of  the  mesentery  lies  beneath 

'  Bnl.  Med.  Journ.  189-5,  vol.  i.  p.  1139. 


548 


THE   INTESTINES 


the  bowel,  where,  if  deemed  advisable,  it  can  be  drained  by 
packing  antiseptic  gauze  down  to  it.  Ligature  tightly  a 
glass  intestinal  drainage  tube  into  the  bowel  above  and  below 
the  tumour,  and  then  cut  away  the  affected  part.  Do  not 
cut  off  first,  or  blood  will  be  unnecessarily  lost.  Only  the 
proximal  tube  is  really  necessary.  The  distal  end  may  be 
closed  or  included  in  the  i^roximal  ligature.     Close  the  ends 


Fig.  96. — Paul's  Method  of  performing  Colectomy 
Preparation  of  the  bowel  for  the  subsequent  safe  removal  of  the  spur 

of  die  wound  with  a  few  silkworm-gut  sutures,  passing 
through  all  the  layers  of  the  abdominal  wall ;  no  others  are 
necessary.  .  .  .  The  second  stage  of  the  operation,  that  of 
breaking  down  the  spur  with  an  enterotome,  should  generally 
be  undertaken  about  three  weeks  later.  As  soon  as  this  has 
been  satisfactorily  accomplished  the  artificial  anus  is  closed 
by  separating  the  rosette  of  mucous  membrane  from  the  skin. 


OPERATIONS— COLECTOM  Y 


649 


turning  it  in,  and  bringing  the  freshened  edges  of  the  latter 
together  over  it.' 

Another  method  of  performing  colectomy  is  to  retain  the 
coil  of  intestine  with  its  affected  area  outside  the  parietal 
wound  until  adhesions  have  sufficiently  shut  off  the  peritoneal 
cavity,  and  then  excise.  When  the  obstruction  caused  is 
acute,  an  opening  is  made  into  the  bowel  above  the  seat  of 
obstruction,  and  so  relief  afforded  by  the  formation  of  an 
artificial  anus.  This  method  of  operating  is  strongly  advo- 
cated by  Greig  Smith  ^  and  by  Harrison  Cripps.^ 

An  operation  for  which  there  exists  no  special  name,  but 


Fig.  97.— Irreducible  Chronic  Ileo-         Fig.  98.— Irreducible  Chronic  Ileo- 
CJ5CAL    Intussusception.      Before  czecal     Intussusception.      After 

Operation  Operation 

Figs.  97  and  98.— Short-circuiting  with  Occlusion  of  a  Portion  of  the 
Intestine.     (Baracz) 

which  somewhat  nearly  approaches  enterectomy,  has  been 
successfully  practised  by  Baracz.^  It  consists  in  severing  the 
continuity  of  the  canal  in  cases  where  the  diseased  segment 
cannot  be  removed,  and  uniting  together  the  unobstructed 
segments  thus  freed.  The  operation  will  be  best  understood 
by  reference  to  the  accompanying  diagrams.     The  complete 

'  Brit.  Med.  Journ.  1895,  vol.  ii.  p.  965. 

••^  Cmtralhlatt  filr  CMmrgie,  1894,  No.  27,  P.  617. 


550  THE  INTESTINES 

occlusion  of  a  portion  of  the  intestinal  tract  does  not  appear  to 
be  fraught  with  any  untoward  results.  In  a  case  reported  by 
Obalinski/  a  portion  of  the  ascending  colon  was  occluded. 
The  patient,  a  female  aged  24,  was  discharged  at  the  end  of 
the  second  month.  The  stools  were  normal  and  regular,  and 
the  patient  quite  well. 

IX«  Colopexy. — This  operation  consists  in  opening  the 
abdomen,  and  fixing  some  part  of  the  colon  by  suture  to  the 
parietal  peritoneum.  It  has  been  performed  for  prolapse  of 
the  rectum ;  and  to  prevent  the  re-formation  of  volvulus  after 
operation  for  untwisting  the  loop. 


CHAPTER  LXVII 

OPERATIONS  (continued)  :  x.  artificial  anus 

X.  Artificial  anus. — By  the  formation  of  an  artificial  anus 
is  understood  an  opening  into  any  part  of  the  small  or  large 
intestine  which  entails  the  necessary  escape  of  all  the  con- 
tents of  the  bowel  above  ;  thus  differing  from  those  operations 
in  which  only  a  portion  may  be  ejected. 

The  anus  receives  its  name  from  the  particular  part  of 
the  bowel  of  which  it  forms  the  termination ;  in  the  case 
of  the  small  intestine  it  is  an  enteric  anus ;  and  in  the  case 
of  the  large,  a  ceecal ;  an  ascending,  a  transverse,  or  descend- 
ing, colonic  ;  and  a  sigmoid,  according  to  the  anatomical  seg- 
ment implicated. 

The  operation  is  performed  for  all  kinds  of  obstruction, 
whether  acute  or  chronic,  and  the  most  frequent  seat  for  its 
performance  is  the  left  inguinal  region.  The  operation  is 
frequently  termed  either  '  inguinal  colotomy  '  or  '  inguinal 
colostomy.'  With  equal  inappropriateness  has  the  term 
*  sigmoidostomy '  been  used. 

Sigmoid  anus. — An  artificial  anus  in  the  sigmoid  flexure  is 
most  frequently  made  for  obstructive  disease  in  the  rectum  or 
lower  part  of  the  sigmoid  flexure. 

Operation. — The  skin  incision  and  the  first  steps  of  the 
operation  to  secure  the  sigmoid  flexure  are  the  same  as  those 

'  CentralblaU  fur  Chirurrjie,  1894,  No.  49,  p,  1193. 


OPERATIONS— ARTIFICIAL   ANUS  551 

for  the  operation  of  sigmoidostomy  (see  page  546).  When 
the  loop  has  been  withdrawn  from  the  parietal  wound  it  is  to 
be  secured  in  position,  and  so  maintained  until  firm  union  is 
estabhshed  between  the  layers  of  the  visceral  and  parietal 
peritoneum.  At  the  end  of  the  fourth  or  fifth  day  this  has 
taken  place,  and  the  operation  is  then  completed  by  opening 
the  bowel,  and  thus  forming  the  anus. 

Such  is  briefly  the  operation.  There  are,  however,  several 
details  which  need  attention,  and  the  carrying  out  of  these 
has  called  forth  many  methods  of  operating.  These  various 
details  may  be  thus  enumerated :  (1)  Difficulty  in  finding  the 
bowel;  (2)  whether  the  loop  is  twisted;  (3)  fixation  of  the 
bowel ;  (4)  prevention  of  prolapse ;  (5)  prevention  of  involun- 
tary evacuations  ;   (6)  subsequent  contraction  of  the  orifice. 

(1)  Dijiculty  in  finding  the  hoicel. —  Cripps  adopts  the 
following  plan :  '  If  the  bowel  does  not  immediately  present 
itself,  it  is  best  found  by  passing  the  forefinger  deeply  into 
the  abdomen,  and  feeling  for  the  brim  of  the  pelvis,  and  by 
sweeping  the  finger  along  the  brim  the  upper  part  of  the 
rectum  can  be  felt  passing  over  it,  and  by  keeping  the  finger 
in  contact  with  this,  it  will  guide  the  operator  to  the  sigmoid 
flexure.' 

(2)  The  twisting  of  the  loop. — To  determine  whether  the 
upper  part  of  the  loop  is  the  proximal  segment,  pass  the 
finger  along  the  bowel  surface  into  the  abdomen,  and  note 
whether  the  gut  then  courses  upwards  or  downwards ;  if  up- 
wards there  is  no  twist. 

(3)  Fixation  of  the  howel. — If  the  mesentery'  is  long 
enough  to  admit  of  the  loop  being  withdrawn,  its  return  into 
the  abdomen  may  be  prevented  in  several  ways.  I  know  of 
no  simpler  or  more  rapid  plan  than  that  of  transfixing  the 
mesentery  immediately  below  the  bowel  wall  with  a  small 
glass  rod,  which  when  passed  rests  on  the  skin  of  the 
abdominal  parietes  on  each  side  of  the  wound.  This  method 
of  transfixing  the  mesentery  was  first  introduced  by  Maydl, 
who  used  a  hard  rubber  cylinder  covered  with  iodoform 
gauze.  Since  then,  other  similar  modifications  have  been 
introduced.  Kelsey  ^  passes  a  hare-lip  pin,  first  through  the 
edge  of  the  wound  at  its  middle,  then  through  the  mesentery 

'  Noio  York  Medical  Record,  1889,  vol.  xxxvi.  p.  398' 


552  THE    INTESTINES 

close  to  the  bowel,  at  the  junction  of  the  lower  and  middle 
third  of  the  exposed  loop,  and  lastly  through  the  edge  of  the 
wound  on  the  opposite  side.  Fixation  may  also  be  effected 
simply  by  suturing.  Thus  Lauenstein  '  passes  sutures  through 
the  mesentery,  and  secures  the  extremities  of  the  loop  by 
careful  stitching.  Allingham  ^  puts  a  stitch  through  the 
skin  on  one  side,  then  through  the  mesentery  behind  the 
bowel,  back  again  through  the  mesentery,  and  ties  to  the  end 
of  the  suture  passed  through  the  skin. 

Whether  any  stitches  should  be  passed  between  the  bowel 
wall  and  the  skin  edge  after  securing  the  mesentery  will 
depend  upon  whether  the  bowel  is  to  be  opened  at  once  or 
left  for  five  or  six  days.  In  the  latter  case  none  need  be 
inserted,  but  in  the  former,  careful  coaptation  should  be 
aimed  at  in  order  to  prevent  the  possibility  of  any  deep 
peritoneal  contamination. 

Where  the  mesentery  is  short,  and  a  loop  cannot  be 
sufficiently  withdrawn  to  admit  of  fixation  as  above  described, 
Cripps's  method  of  forming  a  sigmoid  anus  should  be  per- 
formed, a  plan  of  operating  which  he  adopts  in  all  cases. 

Cripps's  operation.^ — '  An  incision  2^  inches  long  is  made 
at  right  angles  across  an  imaginary  line  drawn  from  the 
anterior  superior  spine  to  the  umbilicus  and  1^  inch  from 
the  superior  spine.  In  order  to  make  the  opening  somewhat 
valvular,  the  skin  should  be  drawn  a  little  inward  and  the 
tissues  divided  until  the  peritoneum  is  reached,  when  this 
should  be  picked  up,  and  incised  to  nearly  the  full  length  of 
the  cutaneous  incision.  The  colon  being  found,  a  loop  of  it 
is  drawn  into  the  wound,  and  if  loose  folds  of  the  sigmoid 
flexure  remain  immediately  above  the  opening,  it  should  be 
drawn  down  and  passed  through  the  fingers  into  the  cavity 
at  the  lower  angle.  When  this  has  been  done,  two  provisional 
ligatures  of  stout  silk  are  passed  through  the  longitudinal 
muscular  band  opposite  the  mesenteric  attachment  2  inches 
apart.  The  bowel  is  now  temporarily  returned  to  the  cavity, 
and  the  parietal  peritoneum  is  sutured  to  the  skin  on  each 
side  of  the  incision  by  two  sutures  of  fine  Chinese  silk,  1| 


Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  iii.  C — 71. 
Brit.  Med.  Journ.  1889,  vol.  i.  p.  769.  »  ji^ig^ 


01'EKATI()2sS— ARTIFICIAL   ANUS  653 

inch  apart,  after  ^\hich  the  bowel  is  fixed  to  the  skin  and 
parietal  peritoneum  by  seven  or  eight  fine  sutures  on  each 
side,  the  last  at  each  angle  going  across  the  one  side  to  the 
other,  and  should  be  so  attached  as  to  have  two-thirds  of  its 
circumference  external  to  the  sutures.  The  sutures  for  the 
lower  side  should  be  passed  through  the  lower  longitudinal 
band,  as  it  is  a  strong  portion  of  the  l^owel.  Those  for  the 
upper  should  be  inserted  close  to  the  mesenteric  attachment.' 

(4)  Prevention  oj  prolapse. — One  of  the  most  troublesome 
sequels  to  the  formation  of  an  artificial  anus  is  the  tendency 
of  the  bowel  to  prolapse  through  the  opening.  It  may  be  the 
upper  or  lower  segment  which  tends  to  project,  but  much  more 
frequently  it  is  the  former.  The  most  radical  measure  for 
the  prevention  of  prolapse  is  that  practised  by  Allingham.' 
After  the  abdomen  is  opened,  the  gut  is  drawn  out  and 
pulled  upon  till  it  is  taut  both  above  and  below — in  other 
words,  the  slack  portion  of  the  gut  is  pulled  out.  This  is 
then  fixed  to  the  skin  edges  by  suturing.  In  two  or  three 
days  the  gut  is  opened  to  allow  the  exit  of  wind ;  and  in  a 
week  or  so  all  the  gut  outside  of  the  belly  is  removed  close 
down  to  the  skin.  As  much  as  a  foot  of  bowel  has  been  thus 
removed.  Cripps  pulls  down  the  bowel  until  it  is  taut  above, 
and  tucks  in  the  slack  below  (see  operation  above).  He 
further  believes  that  by  making  the  incision  through  the 
parietes  higher  than  the  usual  one,  an  additional  inhibition 
to  prolapse  is  added.  He  now  makes  it  nearly  as  high  as  the 
level  of  the  umbilicus,  so  that  the  wall  of  the  lower  half  of 
the  abdomen,  where  the  pressure  is  greatest,  is  left  intact. 

Mansell  Moullin,^  after  making  the  usual  skin  incision, 
'  slits  the  aponeurosis  of  the  external  oblique  and  merely 
separates  the  fibres  of  the  subjacent  muscles  with  the 
handle  of  a  scalpel.  When  the  loop  of  intestine  which  has 
been  selected  is  drawn  out,  the  aponeurosis  on  the  inner  side 
of  the  wound  is  lifted  up  for  about  an  inch  from  the  internal 
oblique,  and  an  incision  made  in  the  direction  of  its  fibres 
that  distance  nearer  the  middle  line.  The  intestine  is  then 
slipped  under  the  isolated  strip,  brought  out  through  the  second 
opening  (the  first  being  closed  again  with  a  suture),  and 
fastened   by   transfixion   of  the   mesentery  in  Maydl's    and 

'  Brit.  Med.  Journ.  1802,  vol.  i.  p.  1013.  -  Ibid.  1893,  vol,  ii.  p.  65, 


554  THE   INTESTINES 

Eeclus'  fashion,  or  in  any  other  way  that  the  operator  pre- 
fers. By  doing  this  the  opening  is  made  valvular,  the 
muscles  are  placed  in  a  position  to  acquire  a  certain  con- 
stricting power  over  it,  and  the  last  inch  or  so  of  the 
intestine  is  made  to  lie  at  an  angle  with  the  part  ahove.' 

(5)  Prevention  of  involuntary  evacuation. — Unfortunately 
there  exists  no  known  means  of  preventing  the  escape  of  the 
faeces  through  the  artificial  anus.  All  mechanical  contri- 
vances, such  as  plugs,  have  proved  failures.  When  once 
peristaltic  action  sets  in,  no  artificial  measures  can  check  the 
fffical  outflow.  The  most  that  can  be  done  is  to  endeavour 
to  keep  the  feeces  solid,  and  so  regulate  them  that  a  move- 
ment may  be  expected  at  a  more  or  less  definite  time,  once  in 
twenty-four  hours. 

(6)  Contraction  of  the  orifice. — It  sometimes  happens  that 
the  orifice  becomes  so  contracted  that  a  constant  faecal  dribbling 
goes  on,  from  the  fact  of  the  bowel  never  being  properly 
emptied.  The  fault  lies  in  the  original  opening  being  too 
small  and  the  union  of  the  surrounding  edges  taking  place 
by  granulation  instead  of  by  first  intention.  When  undue 
contraction  begins  to  show  itself,  the  anus  should  be  dilated 
daily  by  some  form  of  dilator ;  and  if  this  is  not  sufficient 
the  orifice  must  be  incised  to  the  required  extent. 

Another  method  for  forming  an  artificial  anus  in  the 
sigmoid  region  is  to  make  a  transverse  section  of  the  bowel, 
close  the  lower  end  and  return  it  into  the  abdomen,  and 
stitch  the  other  end  to  the  wound.  In  adopting  this  method 
care  must  be  taken  to  ascertain  which  is  the  proximal  and 
which  the  distal  extremity,  otherwise  the  wrong  end  might  be 
occluded. 

Lumbar  anus. — The  first  part  of  the  operation  resembles 
that  for  lumbar  colostomy.  After  identifying  the  bowel,  a 
knuckle  is  brought  outside  the  wound  and  left  in  situ.  No 
stitches,  according  to  Bryant,^  are  necessary,  the  bowel  needs 
only  to  be  protected.  On  the  fourth  or  fifth  day  the  bowel  is 
punctured  with  a  tenotomy  knife,  and  the  opening  enlarged 
for  about  half  an  inch  in  length. 

There  is  no  need  to  describe  the  operations  for  the  forma- 
tion of  an  artificial  anus  in  other  parts  of  the  intestine.     They 

*  Harveian  Lectures,  1894,  p.  39. 


OPERATIONS— ARTIFICIAL    ANUS  555 

are  carried  out  on  much  the  same  Hnes  as  those  for  the  forma- 
tion of  a  sigmoid  or  a  himbar  anus. 

Closure  of  faBcal  fistula  and  artificial  anus, — After  the  opera- 
tions of  colostomy  and  others  of  a  similar  nature  in  other 
parts  of  the  intestine,  it  occasionally  becomes  necessary  to 
close  the  fistula,  and  to  do  so  an  operation  is  requisite. 

In  the  simplest  cases,  where,  for  instance,  no  obstruction 
any  longer  exists  l)elow  the  artificial  orifice,  and  where  the 
fistula  is  only  prevented  from  closing  by  reason  of  a  projecting 
process  of  mucous  membrane,  all  that  is  necessary  is  to  dissect 
away  the  latter  and  draw  together  the  freshened  skin  edges. 

In  cases  where  the  fistula  is  kept  open  on  account  of  a 
projecting  '  spur '  which  prevents  the  free  passage  of  the 
contents  of  the  bowel  above  into  the  segment  below,  means 
must  be  taken  to  remove  it.  The  existence  of  a  '  spur  ' 
indicates  that  a  considerable  portion  of  a  knuckle  of  intestine 
is  adherent  to  the  parietes,  and  that  the  fistula  approaches  that 
of  an  artificial  anus.  The  operation  for  the  remedy  of  this 
condition  is  divisible  into  two  stages  :  the  first  consists  in  the 
destruction  of  the  '  spur  ; '  and  the  second  in  the  closure  of  the 
orifice  in  the  bowel,  and  in  the  parietes.  To  remove  the 
'  spur  '  various  kinds  of  clamps  have  been  invented.  All  have 
the  object  of  causing  the  '  spur  '  to  slough  away  by  the  con- 
tinued pressure  of  the  two  blades  of  the  clamp.  An  enterotome, 
originally  invented  by  Dupuytren  and  known  by  his  name, 
answers  the  purpose  well. 

To  close  the  intestinal  and  the  parietal  orifices,  the  follow- 
ing method  described  by  Chaput  may  be  employed : 

Chapu^'s  operation} — '  The  intestine  is  first  separated  from 
the  abdominal  wall  and  skin  with  a  bistoury.  The  dissection 
should  go  to  a  depth  of  at  least  two  centimetres,  in  order  that 
the  intestine  may  be  sufficiently  free,  but  it  is  not  intended 
to  open  into  the  peritoneal  cavity.  The  exuberant  mucous 
membrane  is  cut  away  with  scissors.  The  muscular  tissue  is 
vivified  by  cutting  either  with  the  scissors  or  by  curetting  for 
at  least  one  centimetre  all  around  the  opening.  The  opposing 
lips  of  the  intestine  are  then  approximated  by  sutures  which, 
turn  the  free  edges  into  the  lumen  of  the  gut.  Deep  catgut 
sutures  are  next  used  for  the  muscular  layer  of  the  abdominal 

'  Kelscy,  Annual  of  the  Universal  Medical  Sciences,  1891,  vol.  iii.  D— 10. 


556  THE    INTESTINES 

wall,  and  finally  the  epidermal  layer  of  the  skin  is  removed 
with  a  sharp  curette  before  the  last  sutures  are  applied.' 

In  order  to  close  an  artificial  anus,  more  radical  measures 
than  those  above  described  are  requisite.  Nothing  short  of 
complete  excision  of  the  anus  will  in  most  instances  suffice. 
The  operation  then  becomes  practically  an  enterectomy. 

The  skin  is  incised  in  the  immediate  neighbourhood  of 
the  anus,  and  the  abdominal  cavity  opened.  The  adhesions 
uniting  the  involved  knuckle  to  the  parietes  are  severed,  and 
the  loop  thus  freed.  The  anus  itself  should  be  cleansed,  and 
stuffed  to  a  sufficient  extent  so  as  to  check  any  possible  con- 
tamination of  the  peritoneal  cavity  by  the  escape  of  faecal 
material.  The  loop  thus  disengaged  is  brought  out  of  the 
parietal  wound  as  far  as  possible,  and  the  operation  of  excision 
then  proceeded  with. 

Senn,^  in  order  to  prevent  more  effectually  the  escape  of 
fffices  through  the  anus  than  can  usually  be  accomplished  by 
plugging  the  orifice,  performs  a  preliminary  transverse  sutur- 
ing of  the  intestinal  opening.  The  sutures  should  include  all 
the  tunics  of  the  bowel,  and  be  placed  so  close  together  that 
any  escaj^e  is  impossible.  With  few  exceptions  this  row  of 
sutures  will  remain  as  Czerny  sutures,  to  be  buried,  after  the 
bowel  has  been  detached,  by  Lembert  stitches. 

The  same  surgeon  advises,  when  extraperitoneal  methods 
are  not  applicable  and  intraperitoneal  operations  are  contra- 
indicated,  the  formation  of  an  anastomotic  communication 
between  the  afferent  and  efferent  limbs  of  the  loop.  The 
opening  should  be  at  least  two  inches  in  length,  and  performed 
either  by  using  decalcified  perforated  bone  plates  or  by  employ- 
ing the  Czerny-Lembert  method  of  suture. 

In  some  cases  of  fsecal  fistula,  where  no  proper  '  spur  ' 
exists,  or,  if  present,  it  is  too  divergent  to  admit  of  the  entero- 
tome  being  safely  applied,  laparotomy  with  excision  and 
suture  will  need  to  be  performed.  Or  if  the  orifice  be  not 
too  large,  its  edges  may  be  pared  and  brought  together  by 
Lembert  sutures  ;  as  was  successfully  accomplished  in  a  case 
operated  upon  by  McGill.^ 

'  American  Journal  of  Obstetrics,  1894,  vol.  xxx.  No.  3,  p.  343. 
'-=  Lancet,  1888,  vol.  i.  p.  121. 


OPERATIONS— APl'ENDICECTOMY  6^7 

CHAPTER   LXVIII 

orERATioNS  {conti lilted)  :    xi.  appendicectomy 

XL  Appendicectomy. — The  operation  consists  in  the  removal 
of  the  appendix  vermiformis  for  disease  connected  with  the  part. 

Operation. — When  appendicectomy  is  performed  during 
the  quiescent  period  in  cases  of  relapsing  appendicitis,  the 
same  precautions  should  be  taken  and  the  same  prepara- 
tions made  as  for  any  other  operation  upon  the  gastro- 
intestinal canal.  The  bowels  should  be  emptied  by  aperient 
medicines,  and  the  use  of  copious  fluid  enemata  on  the  morning 
of  the  operation.  The  skin  is  cleansed  in  the  usual  way,  and 
proper  attention  is  devoted  to  the  clothing  of  the  patient  and 
the  warmth  of  the  operating  room. 

The  patient  is  best  placed  on  the  operating  table  in  the 
Trendelenburg  position  (i.e.  with  the  pelvis  well  elevated), 
so  that  the  small  intestines  will  tend  to  fall  away  from  the 
seat  of  operation.  This  position  should  not  be  assumed  when 
there  is  likely  to  be  a  purulent  collection  about  the  appendix, 
for  fear  of  septic  material  gravitating  into  the  upper  parts  of 
the  general  peritoneal  cavity. 

Skin  incision. — Much  difference  of  opinion  exists  regarding 
the  best  line  for  opening  the  abdomen.  By  some  the  vertical 
incision  is  preferred.  The  peritoneal  cavity  is  opened  by  a  cut  of 
two  and  a  half  or  three  inches  in  extent  carried  along  the  linea 
semilunaris,  its  centre  being  situated  over  the  seat  of  the  ap- 
pendix. By  others,  again,  the  oblique  incision  is  advocated. 
Treves,'  who  practises  this  incision,  takes  an  imaginary  line 
drawn  from  the  anterior  superior  iliac  spine  to  the  umbilicus. 
The  incision  is  about  two  inches  in  length,  is  placed  at  right 
angles  to  this  line,  and  at  a  point  about  two  inches  from  the 
spinous  process.  The  centre  of  the  incision  corresponds  to  the 
line.  McBurney  ^  adopts  the  following  method  :  '  The  incision 
in  the  skin  is  an  oblique  one  about  four  inches  long.  It  crosses 
a  line  drawn  from  the  anterior  iliac  spine  to  the  umbilicus 
nearly  at  right  angles  about  one  inch  from  the  iliac  spine,  and 

'  Brit.  Med.  Journ.  1893,  vol.  i.  p.  830. 
-  Annals  of  Surgery,  1894,  vol.  xx.  p.  38. 


558  THE   INTESTINES 

is  so  situated  that  its  upper  third  Hes  above  that  line.  The 
incision  of  the  aponeurosis  of  the  external  oblique  is  a  little 
shorter,  and  practically  merely  separates  the  fibres  of  that 
muscle  and  its  tendon  without  cutting  them.  The  section  of 
the  internal  oblique  and  transversalis  muscle  follows,  cutting 
the  muscular  fibres  nearly  at  right  angles  to  their  course,  and 
is  completed  only  at  the  central  half  at  first.  This  deeper 
incision  can  be  readily  lengthened  if,  after  cutting  the  fascia 
transversalis  and  peritoneum,  the  character  of  the  lesion  seems 
to  call  for  more  space.'  When  it  is  considered  probable  that 
only  slight  difficulty  will  be  encountered  in  removing  the 
appendix,  and  that  a  comparatively  limited  opening  into  the 
abdominal  cavity  will  suffice,  McBurney  advocates  that  instead 
of  cutting  across  the  fibres  of  the  internal  oblique  and  trans- 
versalis, they  should  be  sej)arated,  and  held  apart  by  a  second 
assistant. 

The  desire  to  prevent  the  possibility  of  subsequent  hernia 
has  now  led  most  surgeons  to  avoid  opening  the  abdomen  in 
the  line  of  fibrous  aponeuroses,  and  always  to  select  incision 
and  separation  of  the  muscular  layers.  Battle  ^  advocates  an 
incision  an  inch  and  a  half  to  the  inside  of  the  linea  semi- 
lunaris, and  divides  the  aponeurosis  of  the  external  oblique 
with  the  sheath  of  the  rectus.  The  rectus  muscle  is  then  drawn 
to  the  inner  side,  and  the  posterior  layer  of  the  sheath  and  trans- 
versalis fascia  exposed,  the  inner  incision  not  corresponding  to 
the  external.  The  peritoneum  is  then  divided.  In  closing  the 
abdomen  the  layers  are  sutured  from  behind  forwards,  and  as 
the  rectus  is  allowed  to  return  to  its  place,  it  thus  interposes 
between  the  internal  and  external  wounds  in  the  abdomen. 

To  find  the  appendix. ^KHqx  opening  the  abdomen,  the 
surgeon  introduces  his  index  finger  in  search  of  the  appen- 
dix, which,  he  must  remember,  may  occupy  one  of  several 
positions  (see  p.  490).  If  any  difficulty  is  encountered,  the 
margins  of  the  incision  should  be  held  well  apart  by  retractors, 
or  the  fingers  of  an  assistant,  and  the  csecum  identified.  The 
latter  is  recognised  by  its  pouched  appearance,  and  by  the 
existence  of  the  three  fiat  longitudinal  muscular  bands.  If 
the  anterior  band  be  traced  downwards,  it  will  lead  to  the 
appendix  (see  Plate  XXV,  tig.  64).     In  cases  of  doubt  regarding 

'  Brit.  Med.  Joiirn.  1895,  vol.  ii.  p.  13G0. 


OPERATIONS -APPENDICECTOMY  r^.W 

the  direction  of  the  colon,  the  appHcation  of  a  bit  of  sodic 
chloride  is  said  to  excite  a  reversed  peristalsis,  and  thus 
indicate  the  direction  to  follow. 

To  remove  tJie  a}>pen<Rx\ — When  the   appendix  has  heen 
isolated    and   brought    within    the    sphere  of   operation,  the 
simplest  and  most  rapid  method  of  its  removal  consists  in 
first  tying  and  dividing  its  mesentery,  and  then  passing  a 
ligature  tightly  around  it  near  its   origin  from  the  c?ecum, 
cutting  it  off  and  then  cleaning  well  or  cauterising  the  end  of 
the  stump.     This  method  may  and  frequently  will  do  perfectly 
well.     It  leaves,  however,  an  element  of  risk,  in  the  piece  of 
mucous  membrane  which  is  necessarily  exposed  and  projects 
from   the    orifice   of   the  stump.     When  the   disease  of  the 
appendix    originates  in    some  inflammatory  affection  of   the 
mucous  lining,  this  latter  is  liable  to  prove  an  infective  focus, 
and  should  therefore  be  securely  dealt  with.     To  attain  this 
object  several  plans  have  been  suggested.    One  of  the  simplest 
is  to  ligature  and  remove  the  appendix  close  to  the  caecum, 
and  then  draw  together  by  a  few  stitches  a  fold  of  the  neigh- 
bouring peritoneum.     The  stump  is  thus  buried.     By  some 
it  is  advised  to  scarify  the  serous  membrane  before  uniting  it 
over  the  stump. 

Treves  •  employs  the  following  method  whenever  possible. 
'  A  circular  cut  is  made  through  the  peritoneum,  just  on  the 
distal  side  of  the  spot  at  which  it  is  intended  to  sever  the 
process.  The  peritoneum  thus  freed  is  turned  back,  like  the 
skin  in  a  circular  amputation,  and  the  appendix  is  cut  across 
at  the  line  of  the  reflected  peritoneum.  The  mucous  mem- 
brane which  presents  is  scraped  away  with  a  sharp  spoon. 
The  muscular  wall  of  the  appendix  is  then  brought  together 
by  means  of  a  continuous  suture  of  No.  1  silk  braid.  Over 
the  stump  thus  formed  the  reflected  peritoneum  is  drawn 
and  secured  in  place  by  means  of  a  few  points  of  Lembert's 
suture.' 

A.  E.  Barker,^  in  order  to  attain  much  the  same  end,  but 
with  the  expenditure  of  less  time,  advocates  that  the  appendix 
be  thus  removed.  '  The  mesentery  is  first  transfixed  and  tied 
in  one  or  two  parts  with  fine  silk  ;  it  is  then  cut  with  scissors 
up  to  the  base  of  the  appendix,  close  to  the  c^cum.     Then,  at 

'  Brit.  Med.  Journ.  1893,  vol.  i.  p.  S3G.     -  Hid.  1895,  vol.  i.  p.  8G3. 


o60  THE    INTESTINES 

about  three-quarters  of  an  inch  from  the  latter,  the  serous 
and  muscular  coats  are  divided  by  a  circular  sweep  of  a  sharp 
knife,  leaving  the  mucous  tube  intact.  The  latter  is  now 
gently  drawn  out,  and  the  two  outer  coats  are  stripped  back 
towards  the  caecum  with  a  director  and  turned  over  like  the 
sleeve  of  a  coat.  In  this  way  the  tube  of  mucous  membrane 
can  be  reached  at  its  point  of  exit  from  the  caecum,  and  is  tied 
with  a  fine  silk  ligature,  and  so  closed.  Then  it  is  cut  across 
an  eighth  of  an  inch  beyond  the  ligature,  and  immediately 
retracts.  The  outer  tube  of  serous  and  muscular  tissue  is 
now  turned  down  over  the  stump  of  mucous  coat,  which  has 
retracted  towards  the  csecum  on  being  divided.  This  tube, 
formed  of  the  outer  coats,  is  then,  instead  of  being  stitched, 
simply  surrounded  with  a  fine  eilk  or  gut  ligature,  and  closed 
over  the  mucous  stump.' 

The  many  complications  and  difficulties  which  may  be 
encountered  in  attempts  to  remove  the  appendix  have  already 
been  described  (see  page  513)  ;  and  from  a  reference  to  these 
it  will  be  seen  what  modifications  of  the  above  mode  of 
operating  may  be  necessary  regarding  the  size  and  position 
of  the  skin  incision,  the  mode  of  dealing  with  the  appendix, 
and  the  after  treatment  of  the  wound. 

XII.  Other  operations.  — There  are  several  other  operations 
in  which  the  bowel  plays  an  important  part,  but  which  it  is 
usual  to  describe  under  other  headings.  Thus  the  operation  of 
gastro-enterostomy  has  been  fnlly  described  in  the  operations 
u23on  the  stomach.  The  operation  of  cholecyst-enterostomy 
is  usually  dealt  with  in  works  upon  diseases  of  the  gall 
bladder ;  a  fistulous  communication  is  formed  between  this 
viscus  and  the  bowel.  The  operation  of  uretero-enterostomy 
consists  in  a  lateral  implantation  of  the  ureters  into  some  part 
of  the  intestine,  usually  the  rectum  or  the  colon.  It  has  been 
successfully  performed  by,  among  others,  Borri  ^  in  two  cases. 
In  one  case  it  was  performed  for  tuberculosis  of  the  bladder  ; 
in  the  other  for  a  large  vesico-vaginal  fistula  with  total 
destruction  of  the  urethra.  An  operation  which  is  called 
'  cystenterostomy '  has  been  devised  for  establishing  a  commu- 
nication between  the  posterior  wall  of  an  extroverted  bladder 
and  the  intestine. 

'  Brit.  lied.  Journ.  Epitome,  1896,  vol.  i.  p.  1. 


PAET   IV 

THE  BECTUM 


CHAPTER    LXIX 

ANATOMY   AND    PHYSIOLOGY.       SURGICAL    ANATOMY.       METHODS 
OF    EXAMINATION 

Anatomy. — The  rectum  extends  from  the  left  sacro-iliac 
synchondrosis  to  the  anus.  It  measures  in  the  adult  about 
eight  inches  in  length,  varying  somewhat  according  to  the 
height  of  the  individual.  In  short  women  it  may  not  be 
longer  than  five  inches.'  It  takes  a  somewhat  winding  course, 
passing  downwards  from  the  left  side  above,  to  the  median 
line,  then  following  the  concavity  of  the  sacrum  and  coccyx, 
and  finally  turning  sharply  backwards  round  the  latter  to 
reach  the  anus.  It  is  constricted  at  the  anus,  and  slightly 
also  at  its  commencement  or  junction  with  the  sigmoid  flexure  ; 
between  these  two  points  it  is  dilated.  In  shape  it  may  be 
roughly  likened  to  a  club,  the  most  dilated  portion  being  below, 
about  an  inch  within  the  anus.  In  some  cases  there  is  a 
tendency  to  pouching  of  the  bowel  forwards,  immediately 
prior  to  its  constriction  at  the  sphincters.  The  rectum  is  kept 
in  a  more  or  less  fixed  position  by  means  of  the  peritoneum 
and  the  recto-vesical  fascia.  The  former,  by  its  attachment 
to  the  sacrum  behind,  after  surrounding  the  upper  portion  of 
the  bowel,  constitutes  a  meso-rectum,  while  the  latter  forms 
a  sheath  which  surrounds  and  supports  the  lower  segment. 

In  order  to  simplify  the  description  of  the  rectum  and 
its  relations,  it  is  divided  into  three  parts— an  vpjyer,  middle, 
and  lower. 

'  Mathews,  Diseases  of  the  Rectum  and  Anus,  1892,  p.  31. 

O  0 


562  THE   EECTUM 

The  vjjjy^y  or  first  portion  extends  from  the  left  sacro-iliac 
synchondrosis  to  the  middle  of  the  third  sacral  vertebra. 
It  measm-es  about  three  and  a  half  inches  in  length,  and 
is  almost  entirely  surrounded  by  peritoneum.  Posteriorly  it 
is  in  contact  with  the  pyriformis  muscle,  the  sacral  plexus  of 
nerves,  and  the  branches  of  the  internal  iliac  artery  of  the 
left  side,  which  separate  it  from  the  sacrum  and  the  sacro- 
iliac joint.  In  front  is  the  recto-vesical  pouch  in  the  male, 
and  Douglas's  pouch  in  the  female,  both  of  which  contain 
coils  of  small  intestine. 

The  middle  or  second  portion  extends  from  the  middle  of  the 
third  sacral  vertebra  to  the  tip  of  the  coccyx.  It  measures 
about  three  inches  in  length,  and  is  covered  by  peritoneum 
on  the  front  and  sides  above,  but  only  in  front  below.  Pos- 
teriorly it  lies  in  the  hollow  of  the  sacrum  and  coccyx,  and  in 
front  it  has  the  trigone  of  the  bladder,  the  prostate,  and  the 
vesiculse  seminales  and  vasa  deferentia  in  the  male,  and  the 
vagina  in  the  female. 

The  lower  or  third  portion  extends  from  the  tip  of  the 
coccyx  to  the  anus.  It  measures  about  an  inch  and  a  half 
in  length.  A  triangular  space  intervenes  between  it  and  the 
membranous  and  bulbous  portions  of  the  urethra  in  the  male, 
and  between  it  and  the  vagina  in  the  female.  The  lower  inch 
of  this  part  constitutes  the  anal  portion  of  the  rectum. 

Structure. — The  structure  of  the  rectum  resembles  in  many 
points  that  of  the  colon ;  it  differs,  however,  in  the  distribu- 
tion and  arrangement  of  its  coats.  Thus  the  external  or 
serous  coat,  formed  by  the  peritoneum,  only  constitutes  a 
tunic  of  the  upper  half  of  the  rectum.  It  surrounds  the 
upper  portion,  forms  the  front  of  the  second  part,  and  only 
exists  on  the  upper  part  of  the  sides  of  the  latter  ;  the  third 
part  has  no  serous  coat.  The  muscidar  coat  is  uniformly 
distributed  around  the  bowel.  The  external  longitudinal 
fibres  are  thicker  above  than  below ;  while  the  internal  are 
thicker  below  than  above,  forming  the  internal  sphincter  at 
the  anus.  The  middle  portion  of  the  levator  ani  muscle  is 
connected  with  the  lower  part  of  the  rectum  ;  its  fibres  are 
prolonged  upon  the  bowel  until  they  blend  with  the  external 
sphincter.  Cripps  ^  maintains  that  the  fibres  of  the  levator 
'  Diseases  of  the  Rectum  and  Amis,  1884,  p.  8.    . 


ANATOMY  563 

ani  pass  from  the  front  and  sides,  backwards  to  the  coccyx,  and 
so  encircle  the  bowel  as  to  have  a  sphincter-like  action  upon  it. 

The  mucous  memhraiie  is  thicker,  redder,  and  more  vascu- 
lar than  that  lining  the  colon.  Like  it,  however,  it  is  covered 
with  the  same  columnar-shaped  epithelial  cells.  The  mucous 
membrane  rests  upon  a  comparatively  lax  submucous  tissue, 
which  admits  of  considerable  freedom  of  movement  upon  the 
muscular  coat.  When  in  a  contracted  condition  the  mucous 
membrane  is  thrown  into  numerous  longitudinal  folds,  which 
disappear  on  distension  of  the  bowel.  Other  folds,  transverse 
or  oblique  in  direction,  are  more  or  less  permanent.  Three 
of  these,  larger  than  the  rest,  are  known  as  Houston's  folds. 
They  are  somewhat  oblique  in  direction,  and  are  half  an  inch 
or  more  in  depth.  '  One  of  these  projects  backwards  from 
the  upper  and  fore  part  of  the  rectum,  opposite  the  prostate 
gland ;  another  is  placed  higher  up,  at  the  side  of  the  bowel ; 
and  a  third  still  higher.' 

The  mucous  membrane  contains  numerous  crypts  of 
Lieberkiihn ;  and  deeper  than  these  glands,  are  scattered 
rounded  lymphoid  follicles  resem])ling  the  solitary  glands  of 
the  small  intestine. 

Vessels  and  nerves  of  the  rectum. — The  arteries  which 
supply  the  rectum  come  from  three  different  sources.  Those 
to  the  upper  part  come  from  the  inferior  mesenteric,  and  are 
known  as  the  superior  luemorrJioidal ;  those  to  the  middle 
portion  are  the  middle  luemorrJioidal,  branches  of  the  internal 
iliac;  and  those  to  the  lowest  segment  the  inferior  hcemorrlioidal, 
branches  of  the  pudic  artery.  In  the  upper  half  of  the  rectum 
the  arteries  perforate  the  muscular  coat  and  form  a  network 
in  the  submucous  tissue.  In  the  lower  half,  the  vessels,  after 
penetrating  the  muscular  coat,  take  a  longitudinal  course 
towards  the  anus,  where  they  finally  join  by  numerous  trans- 
verse branches. 

The  veins  follow  the  distribution  of  the  arteries.  Com- 
mencing as  a  plexus  at  the  lowest  part  of  the  bowel,  they 
pass  upwards,  and  end  by  joining  branches  which  terminate 
in  the  internal  iliac  vein  and  in  the  inferior  mesenteric 
vein.  Blood  is  thus  returned  to  the  vena  cava,  either  directly 
through  the  iliac  veins  or  indirectly  through  the  portal 
system. 

o  o  2 


664  THE   RECTUM 

The  lymphatic  vessels  are  of  large  size.  They  pass  from 
the  bowel  through  small  glands  which  lie  on  its  outer  wall, 
and  then  upwards  by  the  meso-rectum  to  the  sacral  and 
lumbar  glands. 

The  nerves  are  derived  mostly  from  the  pelvic  plexuses 
of  the  sympathetic,  which  are  derivatives  of  the  hypogastric 
plexus,  situated  in'  front  of  the  upper  part  of  the  sacrum. 
Some  branches  also  pass  from  the  sacral  plexus  of  the  cerebro- 
spinal system. 

Physiology. — The  rectum  when  at  rest  is  usually  empty, 
and  the  mucous  walls  in  contact.  The  descent  of  faeces  into 
the  canal  usually  induces  the  act  of  defecation.  The  rectum 
can,  however,  act  as  a  temporary  receptacle  for  the  faeces 
until  then'  voluntary  ejection.  Normal  defecation  consists 
in  the  continuance  of  a  peristaltic  wave  which  commences 
in  the  intestine  above  and  continues  downwards,  until  the 
relaxed  sphincters  admit  of  the  escape  of  the  faeces.  Too 
violent  ejection  is  supposed  to  be  somewhat  checked  by 
Houston's  valves,  which  retard  the  downward  progress  of  the 
faeces.  These  valves  also  serve  to  support  the  contents  and 
prevent  undue  pressure  upon  the  sphincters. 

The  action  of  the  levator  ani  is  considered  by  some  to  be 
of  the  nature  of  a  sphincter ;  by  others  to  give  support  to  the 
lower  part,  and  by  contracting,  to  draw  it  up  and  invert  its 
anal  border  after  defecation. 

The  mucous  membrane  secretes  mucus  for  the  lubrication 
of  the  faeces,  to  facilitate  their  passage  through  the  anus. 

Free  absorption  of  fluids  takes  place  ;  and,  as  shown  by 
the  successful  employment  of  enemata,  the  bowel  also  absorbs 
certain  solid  ingredients  when  administered  in  a  suitable  form. 

Surgical  anatomy. — "When  the  finger  is  inserted  into  the 
rectum  the  involuntary  contraction  of  the  sphincters  is  felt 
for  about  an  inch  up  the  bowel.  If  the  patient  is  made  to 
voluntarily  draw  up  the  bowel,  '  the  upper  margin  of  the  con- 
tracted portion  ends  abruptly  and  gives  a  sensation  of  a  broaid 
muscular  band  round  the  bowel.'  This  Cripps  ^  attributes  to 
the  voluntary  contraction  of  the  levator  ani  muscle. 

With  the  finger  thus  inserted  the  shape  and  capacity  of 

'  Diseases  of  the  Rectum  and  Anus,  1884,  p.  3. 


ANATOMY  AND  PHYSIOLOGY  565 

the  bowel  can  be  recognised.  If  the  rectum  be  first  partially 
distended  with  water,  a  better  notion  is  obtained  of  its  size. 

While  the  finger  cannot,  in  the  majority  of  adult  cases,  reach 
much  beyond  three  to  four  inches,  this  will  as  a  rule  embrace 
that  part  of  the  bowel  which  is  uncovered  by  peritoneum. 
Downward  pressure  on  the  part  of  the  patient  increases  the 
length  which  can  be  examined.  The  depth  to  which  the 
recto-vesical  peritoneal  pouch  may  descend  depends  upon  the 
empty  or  distended  condition  of  the  bladder.  According  to 
Cripps,^  the  distance  from  the  anus  to  the  peritoneum  is  only 
two  and  a  half  inches  when  the  bladder  and  rectum  are  empty  ; 
but  when  distended,  an  additional  inch  is  added. 

In  the  male  the  finger  within  the  rectum  detects  on  the 
anterior  surface,  about  an  inch  and  a  half  to  two  inches  from 
the  anus,  the  prostate  gland.  In  front  of  this  exists  the 
membranous  part  of  the  urethra  which  is  recognised  on  the 
passage  of  a  catheter.  Posterior  to  the  prostate  is  felt  the  apex 
of  the  trigone  of  the  bladder,  with  the  ejaculatory  ducts,  and 
the  vesiculae  seminales  on  each  side.  In  children  the  bladder 
in  its  entirety  can  be  easily  palpated  bimanually.  The 
finger  can  also  detect  the  pulsation  of  the  hgemorrhoidal 
arteries,  and  distinguish  one  or  more  of  Houston's  folds. 
Laterally  there  is  felt  the  soft  unresistant  tissues  of  the  ischio- 
rectal fossffi. 

In  the  rectum  of  the  female  the  os  uteri  is  distinctly 
felt  on  the  anterior  wall ;  and  anterior  to  this  is  the  thin 
septum  between  the  rectum  and  the  vagina. 

The  upper  portion  of  the  rectum,  and  the  parts  in  relation 
to  it,  can  only  be  detected  by  the  introduction  of  the  hand. 
In  addition  to  the  facts  ascertainable  by  the  finger  and  given 
above,  the  following  points  are  elicited :  '  Through  the  pos- 
terior wall  of  the  bowel  the  coccyx  and  sacrum  can  be  felt, 
the  curve  of  the  sacrum  being  readily  followed  by  the  hand. 
The  projecting  spine  of  the  ischium  on  each  side  of  the  pelvis 
is  a  valuable  landmark.  From  this  point  the  outlines  of  the 
greater  and  lesser  sacro-ischiatic  foramina  can  be  traced  by 
the  fingers.  ...  If  the  hand  be  now  pushed  farther  up  the 
gut,  the  promontory  of  the  sacrum  is  reached  ;  the  pulsation 
of  the  iliac  vessels  becomes  manifest,  and  the  course  of  the 

'  Diseases  of  the  Rectum  and  Anus,  1884,  p.  3. 


566  THE  RECTUM 

external  iliac  can  be  traced  along  the  brim  of  the  pelvis  to  the 
crural  arch.  .  .  .  The  internal  iliac  artery  can  also  be  followed 
to  the  upper  part  of  the  great  sacro-ischiatic  foramen.  By 
semi-rotatory  movement,  and  alternately  flexing  and  extending 
the  fingers,  the  hand  can  gradually  be  insinuated  into  the 
commencement  of  the  sigmoid  flexure.  In  the  sigmoid 
flexure  the  fingers  can  explore  the  whole  of  the  lower  part  of 
the  abdomen.  ...  In  the  female,  the  uterus  in  the  middle 
line,  and  the  ovaries  on  either  side,  can  be  readily  dis- 
tinguished.' ^  (Walsham.) 

In  introducing  the  hand  into  the  rectum,  two  fingers 
should  be  inserted  first,  then  the  other  two,  and  lastly  the 
thumb.  The  passage  of  the  hand  is  facilitated  by  freely 
lubricating  it  with  vaseline  or  lard,  and  by  the  application  of 
the  other  hand  upon  the  abdomen.  Progress  should  be 
effected  by  a  careful  rotatory  motion  of  the  hand.  As  regards 
the  size  of  the  hand  which  it  is  possible  to  introduce  without 
causing  immediate  danger  or  subsequent  incontinence  of 
faeces,  it  naturally  follows  that  the  smaller  the  hand  the  less 
must  be  the  untoward  consequences.  Walsham's  hand 
measured  somewhat  less  than  seven  and  a  half  inches. 
Mathews^  had  success  in  using  his  hand,  which  measured 
eight  and  a  quarter  inches.  Bryant,^  in  a  case  already 
quoted,  succeeded  with  his  hand,  which  measures  nine  and  a 
quarter  inches  ;  and  Mathews  quotes  Simon  in  maintaining 
'  that  a  hand  measuring  twenty-five  centimetres  (nearly  ten 
inches)  may  be  introduced  absolutely  without  harm.' 

Metliod  of  perforniing  rectal  examination. — Prior  to  any 
examination  of  the  rectum,  it  is  advaiitageous,  when  possible, 
to  administer  a  water  enema.  One  of  three  positions  is 
usually  adopted  for  examination.  The  patient  is  either  placed 
on  the  side,  or  on  the  back,  or  on  the  knees  and  chest.  In  the 
lateral  position,  the  patient  lies  on  a  couch  or  table  of  ordinary 
height,  preferably  on  the  left  side,  with  the  knees  flexed  and  the 
thighs  drawn  up.  In  the  dorsal  position,  the  knees  and  thighs 
are  flexed  and  abducted,  the  position  being  the  same  as  that  for 
lithotomy.  In  both  these  ijositions  the  pelvis  should  be  raised 
upon  a  pillow,  so  that  the  intestines  gravitate  away  from  the 

'  St.  Bartholonieio^s  Hosintal  Reports,  1876,  vol.  xii. 

'  Diseases  of  the  Rectum  and  Anus,  1892,  p.  25.  '  See  p.  449. 


INJURIES  o67 

pelvis.  In  the  knee-breast  posture,  the  patient  kneels  upon 
the  table  with  the  chest  resting  upon  the  arms  folded  across 
the  table. 

The  index  finger  of  the  right  hand  is  lubricated  with 
vaseline  or  some  ointment  such  as  iing.  hydrarg.  By  slow 
and  gradual  insertion  the  contraction  of  the  sphincter  is  over- 
come, and  the  finger  introduced  without  causing  much  pain. 

When  it  is  desirable  to  see  the  parts  as  well  as  feel  them, 
one  of  the  many  forms  of  rectal  speculum  is  introduced  with 
the  same  precautions  as  the  finger.  If  good  natural  light, 
cannot  be  obtained  some  artificial  means  must  be  employed ; 
and  for  this  purpose,  lamps  with  reflectors  are  sometimes 
used.  An  excellent  method  is  to  reflect  a  light  from  an 
ordinary  laryngoscopic  mirror  fixed  on  the  surgeon's  forehead, 
Leiter's  panelectroscope  is  also  a  convenient  instrument  for 
rectal  illumination. 

Whether  the  finger  or  the  speculum  be  used,  not  only 
should  the  lining  wall  of  the  gut  be  carefully  examined,  but 
it  should  be  noted  whether  either  on  withdrawal  is  tinged 
with  blood,  mucus,  or  purulent  material. 


CHAPTER  LXX 

INJURIES.      FOREIGN    BODIES.      FiECAL    CONCRETIONS 

The  deep  and  protected  position  of  the  rectum  within  the 
osseous  walls  of  the  pelvis  renders  it  specially  exempt  from 
all  those  forms  of  injury  which  are  liable  to  affect  the  other 
more  exposed  parts  of  the  gastro.-intestinal  canal.  The  region 
of  the  perineum,  and  the  orifice  of  the  rectum  itself,  naturally 
form  the  most  vulnerable  parts..  Hence  nearly  all  injuries 
are  inflicted  by  the  impingement  of,  or  the  introduction  of 
bodies  into,  this  region.  The  only  exceptions  are  gunshot 
wounds  and  severe  fractures  of  the  pelvis.  In  a  case  recorded 
by  Earle,'  a  fracture  of  the  pelvis  caused  an  extensive  lacera- 
tion which  communicated  with  the  rectum. 

Injuries  which  result  from  some  impingement  are  among 
the  commonest  and  most  severe  of  wounds  of  this  region.     A 

'  Trans.  Mcd.-Chir.  Soc.  Loud.  1835,  vol.  xix.  p.  257. 


568  THE  RECTUM 

fall  upon  some  more  or  less  hard  and  pointed  body  results  in 
the  latter  entering  the  perineum  and  cutting  or  lacerating  the 
walls  of  the  bowel  and  the  tissues  surrounding  it.     Injuries 
of  this  nature  are  accidental.     On  the  other  hand,  injuries  of 
various   degrees   of  magnitude  have  been  produced  by  the 
voluntary  introduction  of  agents  of  various  kinds  through 
the  anus.     In  some  instances,  bodies  have  been  introduced 
with  the  object  of  temporary  concealment ;  while  in  others 
they  have  been  employed  for  special  purposes.     Among  the 
latter  it  is  interesting  to  note  that  severe  injury  has  been  in- 
flicted by  surgeons  in  making  use  of  the  rectum  for  operative 
purposes  elsewhere.     Thus  rupture  of  the  rectum  has  followed 
its  distension  by  Petersen's  bag,  in  performing  suprapubic 
cystotomy.     Fowler  '  records  such  an  instance,  and  refers  to 
two  others,  by  Cadge  and  by  Nicaise.     In  all  three  a  fatal 
result  ensued.     Another  source  of  injury  has  been  in  the  use 
of  Davy's  lever  for  compression  of  the  common  iliac  artery 
in  amputation  at  the  hip  joint ;  and  a  similar  source  is  found 
in  the  forcible  introduction  of  solid  bougies  for  stricture,  which 
have  been  made  to  perforate  the  upper  part  of  the  bowel  wall 
and  cause  death  by  peritonitis.     Such  a  simple  procedure  as 
the   introduction  of  enemata  has  been  "followed   by   serious 
results.     Nordman  ^  refers  to  twenty-five  such  cases.     They 
include   three   complete   perforations    and    ulcerations,    and 
wounds  of  various  depths  and  sizes.     The  causes  of  these 
lesions  seem  to  have  been  the  use  of  defective  instruments, 
ignorance  of  the   direction  of  the  rectum,  catching  of  the 
transverse  fold  on  the  tube,  extensive  irritation  of  the  mucous 
membrane  of  the  bowel,  and  obstructions  caused  by  certain 
conditions  of  the  uterus,  by  the  foetal  head  in  parturition,  or 
by  an  enlarged  prostate.     These  lesions  are  usually  found  on 
the  anterior  wall  of  the  rectum,  from  one  to  seven  centimetres 
from  the  anus. 

The  rectum  has  also  been  injured  by  the  surgeon  in  cut- 
ting for  stone  in  perineal  lithotomy,  both  in  the  median  and 
the  lateral  operation. 

Injuries  usually  of  a  slighter  nature  are  effected  by  foreign 

'  Annals  of  Surgery,  1890,  vol.  xii.  p,  129. 

*  Neto  York  Med.  Journ.  1888,  vol.  xlviii.  p.  43. 


INJUIilES  569 

bodies  passing  into  the  bowel  from  above.     These,  however, 
will  be  alluded  to  later. 

Kuptures,  lacerations,  and  contusions  of  the  anterior  wall 
are  produced  during  parturition.  Injuries  of  this  character 
are  usually  more  fully  described  in  works  on  Gynaecology. 

Nature  of  injury  inflicted. — The  agent  inflicting  the  injury 
chiefly  determines  the  kind  of  lesion  produced.  It  may  be  of 
the  nature  of  a  contused,  incised,  punctured,  or  lacerated  wound. 
The  higher  the  seat  of  the  injury  the  more  likelihood  is  there 
of  the  peritoneal  cavity  being  involved.  The  extreme  vascu- 
larity of  the  bowel,  and  the  want  of  any  firm  support  to  the 
vessels,  renders  considerable  hgemorrhage  possible. 

Results  of  injury. — Injuries  which  involve  a  part,  and  not 
the  entire  bowel  wall,  usually  heal  well.  When,  however,  the 
whole  thickness  of  the  wall  is  involved,  complications  are  liable 
to  be  present,  or  subsequently  arise  from  injuries  inflicted 
upon  neighbouring  parts.  Complete  perforation,  rupture,  or 
laceration  occurring  in  the  upper  half  of  the  rectum  may 
open  the  general  peritoneal  cavity ;  while  like  lesions  occur- 
ring lower  down  may  open  the  bladder  or  urethra  in  the 
male,  or  the  vagina  in  the  female. 

Inflammation  arising  as  the  result  of  injury  may  be  limited 
to  the  bowel  wall,  causing  either  a  localised  or  a  general 
proctitis.  This  may  end  in  ulceration  or  sloughing,  especially 
if  there  has  been  laceration  of  the  parts,  and  this,  too,  may 
end  at  a  later  period  in  the  formation  of  stricture. 

When  inflammation  has  extended  into  the  perirectal  tissue, 
abscess  may  form,  and  if  it  does  not  discharge  into  the  bowel, 
it  may  burrow  and,  as  in  the  case  narrated  below,  open  ex- 
ternally. Abscesses  which  burst  into  the  bladder  may  lead  to 
recto-vesical  fistulse. 

Symptoms. — The  severity  and  nature  of  the  injury  wil 
mostly  determine  the  character  of  the  symptoms.  Bleeding 
may  prove  a  prominent  feature  where  much  laceration  of  the 
bowel  wall  has  taken  place,  but  neither  its  presence  nor  its 
absence  must  be  counted  upon  as  any  true  criterion  of  the 
nature  of  the  wound.  Pain  may  be  felt  both  in  the  region 
itself,  and  reflexly  in  other  parts,  as  above  the  pubes,  and 
in  the  perineum.  Any  '  movement '  of  the  bowels  will  cause 
pain.     These  various  symptoms  become  augmented  if  inflam- 


570  THE   RECTUM 

mation  sets  in ;  fever  and  other  constitutional  disturbances 
are  then  added.  In  a  case  reported  by  J.  H.  Thompson/ 
there  was  a  remarkable  absence  of  all  symptoms  except 
abdominal  pain,  which,  while  only  slight  at  first,  became  severe 
a  short  time  before  death.  The  case  was  that  of  a  lad  aged 
18  years,  who  had  fallen  about  four  feet  in  a  sitting  posture 
on  to  the  end  of  the  upright  shaft  of  a  smith's  hammer.  It 
entered  the  anus,  lacerated  and  passed  through  the  rectum 
about  three  inches  up,  and  carried  a  piece  of  cloth  into  the 
abdominal  cavity,  where  it  was  found  at  the  post  mortem.  In 
the  motion  and  in  the  urine  which  were  passed  no  blood  was 
present,  and  the  lad  died  on  the  same  day  from  collapse. 

Treatment. — The  only  immediate  treatment  that  is  likely  to 
be  required  will  be  to  check  any  undue  haemorrhage.  When 
possible,  bleeding  points  should  be  secured  by  ligature ;  failing 
such  means,  compression  should  be  exercised  by  the  insertion 
of  a  tube  or  catheter  wound  round  with  some  antiseptic  tissue 
to  the  required  diameter.  Any  complication  existing  at  the 
time,  or  arising  subsequently,  must  be  dealt  with  on  general 
surgical  lines. 

Case  CII. — Injury  to  rectum:  abscess  formation.    Recovery. 

A  farm  labourer  aged  35  years  slid  from  the  top  of  a  hayrick  on  to  a 
long-handled  shovel.  The  handle  entered  his  anus.  The  impetus  of  the 
descent  carried  him  to  the  ground  attached  to  the  shovel,  which  he  ex- 
tracted, and  which  he  said  had  entered  to  a  depth  of  four  inches.  At  the 
time  of  the  injury  he  felt  severe  pain  in  the  abdomen.  His  bowels  did 
not  act  that  day,  although  he  several  times  felt  a  desire  to  go  to  stool. 
The  following  day  he  took  castor  oil,  and  repeated  the  dose  the  next  day, 
when  his  bowels  moved,  and  he  then  suffered  from  diarrhoea  for  several 
days.  The  pain  in  his  abdomen  persisted,  and  settled  in  the  right  iliac 
region.  Four  days  after  the  accident  he  noticed  a  swelling  in  the  right 
groin,  which  gradually  extended  over  the  outside  of  the  right  thigh.  His 
temperature  rose  to  103°,  and  his  general  condition  was  that  of  one  suffer- 
ing from  septicaemia.  The  right  thigh  became  swollen  and  red,  almost 
down  to  the  knee.  Palpation  then  elicited,  on  the  front  and  outer  part  of 
the  thigh,  fluctuation  and  '  a  squashing,  gui-gling  sound.' 

An  examination  of  the  rectum  at  this  period  detected,  on  the  right 
side,  about  three  inches  from  the  anus,  a  roughly  circular  hole  about  one 
inch  in  diameter,  with  rugged  edges  ;  and  a  swelling  could  be  felt  occupy- 
ing the  right  side  of  the  pelvis. 

On  opening  the  swelling  a  quantity  of  exceedingly  offensive  gas  and 
pus  escaped.     Improvement  then  took  place  for  a  time,  when  rigors  and 

'  Lancet,  1887,  vol.  ii.  p.  1110. 


FOREIGN   BODIES— CONCKETIUXS  ^71 

a  high  temperature  appeared.  This  passed  off,  but  a  sinus  persisted 
which  opened  and  closed,  sometimes  emitting  flatus,  and  sometimes  an 
odourless,  serous  fluid.  After  two  or  three  more  relapses  he  eventually 
recovered.     (P.  L.  Townley, '  Australasian  Medical  Gazette,'  1892,  vol.  xi. 

p.  yu8.) 

Foreign  bodies.  Faecal  concretions. — By  foreign  bodies  in 
the  rectum  is  understood  only  such  as  become  impacted  and 
give  rise  to  symptoms.  The  class  is  a  large  one,  because  it 
embraces  two  sources  from  which  these  substances  may  be 
derived.  Either  they  descend  into  the  rectum  from  above,  or 
they  are  introduced  into  it  through  the  anus. 

With  regard  to  the  former  source,  the  *  bodies '  consist 
either  of  materials  ingested  or  of  those  formed  within  the  in- 
testinal canal,  mostly,  however,  of  the  former.  These  may  be 
articles  of  ordinary  diet,  such  as  fish  bones,  chicken  bones, 
and  parts  of  foods  which  fail  to  be  digested  in  their  passage 
through  the  stomach  and  intestines ;  or  they  may  consist  of 
such  foreign  materials  as  nails,  pieces  of  cloth,  &c.  Stalkert  ' 
records  the  case  of  a  boy  aged  10  years,  whose  rectum  became 
blocked  with  a  mass  of  wheat  grains.  The  grains  were  swal- 
lowed entire,  and  had  been  taken  by  the  boy  from  a  vessel 
unloading  in  dock.  The  mass  was  scooped  out  from  the 
rectum,  and  all  symptoms  disappeared.  Avery  similar  case  is 
also  recorded  by  Sympson,^  where  a  quart  of  wheat  grains  was 
removed,  the  patient  at  once  being  relieved  of  his  symptoms. 
An  interesting  account  of  twenty  cases  of  foreign  bodies  im- 
pacted in  the  rectum  is  given  by  Good  sail ;  ^  the  materials 
consisted  in  almost  all  instances  of  bones,  mostly  from  fish. 
Some  of  the  inferences  drawn  from  these  cases  are,  that  the 
accident  is  more  commonly  met  with  after  thirty-five  years 
of  age  :  that  a  bone  takes  from  one  to  nine  days  to  pass  from 
the  mouth  to  the  rectum  :  that  the  pain  comes  on  suddenly 
AAhile  the  motion  is  being  passed  :  that  there  is  constant  pain 
or  discomfort  in  the  rectum  and  sometimes  also  in  the 
subjacent  parts,  from  the  time  of  the  puncture  until  the 
ioreign  body  has  been  removed  ;  and  that  the  site  of  the 
puncture  is  within  the  last  inch  or  three-quarters  of  an  inch 
of  the  anus. 

'   Brit.  Med.  Jonrn.  1890,  vol.  ii.  p.  685.  *  lUd.  p.  790. 

^  St.  Bartholomew's  Ilosintal  Eejports,  1887,  vol.  xxiii.  p.  71. 


572  THE   RECTUM 

When  derived  from  the  latter  source,  there  is  no  limit  to 
the  extraordinary  number  and  nature  of  the  articles  which 
patients  from,  most  varied  motives  may  introduce  into  the 
rectum.  The  following  briefly  abstracted  cases  will  sufficiently 
indicate  a  few  of  these  aberrant  features. 

Lowe  '  reports  the  case  of  a  man  aged  70  years,  who,  wish- 
ing to  commit  suicide,  pushed  up  his  rectum  the  handle  of  a 
drawer  of  a  kitchen  dresser  ;  it  measured  two  and  three-quarter 
inches  in  circumference.  Jenkins  ^  records  the  case  of  a  man 
who  was  robbed  of  his  money,  and  prevented  from  following  the 
thieves  by  the  pain  caused  by  a  turnip  and  a  potato  which  they 
had  forcibly  introduced  into  his  rectum.  The  potato  had  been 
previously  fitted  into  a  hole  in  the  turnip  ;  the  dimensions  of 
the  bulk  were  ten  and  a  half  inches  in  its  bipolar  circumference, 
and  eight  inches  round.  Warren  ^  relates  the  case  of  a  man 
who  for  sexual  purposes  introduced  a  catsup  bottle  up  his 
rectum.  The  bottle  measured  nine  inches  in  circumference 
and  was  ten  inches  in  length.  It  was  removed  by  incising 
the  sphincter.  Other  cases  are  quoted.  Spanton  ^  records 
the  case  of  a  man  who,  for  the  purpose  of  pushing  up  the 
bowel  some  butter  which  he  was  in  the  habit  of  using  for  de- 
stroying '  seat  worms,'  sat  upon  a  hock  bottle.  As  all  attempts 
at  removal  from  below  were  fruitless,  the  bottle  was  removed  by 
colotomy.  The  patient  died  the  following  day.  The  bottle  was 
eleven  inches  long,  and  two  and  a  half  inches  in  diameter  at  its 
lower  part.  Simmons  *  reports  the  case  of  a  man  who  used  a 
stick,  ten  inches  long  and  two-thirds  of  an  inch  in  diameter,  to 
push  up  his  piles.  The  stick  slipped  out  of  his  reach,  and 
was  successfully  withdrawn  with  the  small  obstetric  forceps. 

For  many  other  curious  and  remarkable  illustrations  of 
this  condition,  Poulet's  exhaustive  treatise  upon  '  Foreign 
Bodies  in  Surgery  '  ^  should  be  consulted. 

The  impaction  of  faeces  within  the  rectum  owes  its  origin  to 
various  causes.  In  some  cases  a  want  of  tone  in  the  muscular 
wall  of  the  bowel  allows  of  a  gradual  distension  of  the  part. 
As    a   result    of  prolonged   retention,   and    the   consequent 

'  St.  Bartholomew's  Hospital  Reports,  1891,  vol.  xxvii.  p.  57. 
*  New  York  Med.  Journ.  1894,  vol.  lix.  p.  531. 
'  Boston  Med.  and  Surg.  Journ.  1890,  vol.  cxxii.  p.  543. 
-    *  Brit.  Med.  Journ.  1881,  vol.  i.  p.  848. 
^  New  York  Med.  Journ.  1894,  vol.  lix.  p.  596.  «  Vol.  i.  p.  217. 


FOREIGN   BODIES-CONCRETIONS  57.'} 

absorption  of  all  fluid  constituents,  the  faecal  mass  assumes 
a  more  solid  and  compact  consistency  until  it  forms  a  hard 
mass  which  no  voluntary  effort  on  the  part  of  the  patient  can 
expel.  In  other  cases  a  concretion,  which  may  possibly  have 
a  fish  bone  or  other  like  substance  as  a  nucleus,  forms  in  the 
bowel  above,  and  then  descending  into  the  rectum,  gets  lodged 
in  a  mucous  fold  or  pouch,  where  by  fgecal  accretion  it  enlarges, 
and  finally  becomes  too  large  for  expulsion.  Fenwick  ^  re- 
cords the  case  of  a  man  who  for  some  years  had  suffered  from 
chronic  cystitis  and  constant  diarrhoea  with  frequent  desire  to 
empty  his  bowels.  On  examination  of  the  rectum  a  calculus 
was  felt,  and  withdrawn  with  some  difficulty  by  a  pair  of  litho- 
tomy forceps.  The  rectal  symptoms  disappeared,  and  the 
bladder  trouble  markedly  decreased.  The  calculus  weighed  an 
ounce  and  a  half,  and  on  section  a  plum  stone  was  found 
forming  a  nucleus  to  several  laminae  of  concentrically  disposed 
resinous  material. 

Symptoms. — Considerable  variation  necessarily  exists  in  the 
symptoms  which  may  be  present  in  any  case  of  impacted 
foreign  body,  for  the  j)atient's  sufferings  must  largely  depend 
upon  the  character  of  the  body  impacted  and  the  injury  in- 
flicted upon  the  bowel  wall.  Further,  the  completeness  with 
which  the  canal  is  blocked  will  influence  very  naturally  the 
amount  of  constitutional  disturbance. 

In  its  simplest  effects  a  foreign  body  may  cause  no  further 
distress  than  an  ill-defined  sense  of  discomfort,  from  which  the 
patient  only  gets  relief  by  a  complete  evacuation  of  the  bowels. 
In  cases,  however,  where  the  impaction  means  some  perfora- 
tion of,  or  undue  pressure  upon,  the  bowel  wall,  pain  becomes 
a  prominent  and  often  excruciating  symptom,  felt  in  the 
region  itself,  and  often  in  the  abdomen,  and  in  the  perineum. 

The  patient  frequently  becomes  greatly  distressed  at  his 
own  ineffectual  efforts  at  extraction  or  expulsion,  and  constant 
straining  and  tenesmus  leads  to  a  patulous  and  swollen  con- 
dition of  the  mucous  membrane  at  the  anus.  Frequency 
of  micturition  may  exist  either  from  undue  pressure  upon 
the  bladder  or  from  reflex  nerve  irritation.  Pressure  on  the 
sacral  plexus  posteriorly  may  cause  pain  to  radiate  down  the 
lower  extremities.  Blood,  in  variable  quantity,  is  occasionally 
'  Trans.  Path.  Soc.  Loud.  1886,  vol.  xxxvii.  p.  261. 


r,74  THE   RECTUM 

discharged  from  the  anus,  and  as  thne  progresses,  this  may 
be  mixed  with  mucus  or  pus,  indicating  the  appearance  of 
inflammation  and  ulceration.  Constipation  is  a  common 
symptom  in  most  cases ;  hut  while  no  soHd  motion  is  passed, 
some  offensive  sHmy  material  is  frequently  expelled,  as  the 
result  of  constant  efforts  to  get  relief.  A  curious  exception 
to  the  usual  symptoms  met  with  in  this  class  of  cases  is 
afforded  by  a  case  recorded  by  Lowe.^  A  lady  aged  57  years 
always  felt  as  if  the  action  of  her  bowels  was  incomplete, 
although  well-formed  motions  were  passed.  On  digital  exami- 
nation of  the  rectum,  a  foreign  mass  was  felt  to  have  been 
caught  by  a  fold  of  mucous  membrane,  which  formed  a  pouch 
in  which  it  rested.  It  was  the  size  of  a  turkey's  egg.  All 
symptoms  disappeared  after  its  removal. 

Diagnosis. — Much  difficulty  frequently  exists  in  attributing 
the  symptoms  to  their  true  cause,  and  in  detecting  the  pre- 
sence of  a  foreign  body  when  suspected.  Most  difficulty  in 
diagnosis  is  encountered  in  those  cases  where  the  foreign  body 
has  descended  from  above  into  the  rectum.  Whether  the 
obstruction  be  complete  or  only  partial,  it  is  often  only  by 
careful  digital  examination  that  the  source  of  the  trouble  is 
found.  Should  perchance  the  '  body  '  or  '  bodies  '  be  impacted 
at  the  upper  part  of  the  rectum,  the  real  source  of  obstruction 
may  not  be  detected  until  after  the  abdomen  has  been  opened. 
'  Bodies  '  introduced  _2Jer  annm  do  not  as  a  rule  pass  out  of 
reach  of  the  finger  ;  exceptions,  however,  occasionally  occur,  as 
instanced  by  Simmons'  case  narrated  above.  In  this  latter 
class,  assistance  is  often  obtained  from  the  confession  of  the 
patient,  the  severity  of  whose  symptoms  no  longer  permits 
him  to  conceal  the  true  cause  of  his  sufferings.  The  best 
indication  of  the  existence  of  an  impacted  foreign  body  is  the 
sense  conveyed  to  the  patient  of  something  within  the  rectum 
which  constant  calls  to  stool  fail  to  relieve. 

Prognosis. — If  the  foreign  body  has  remained  only  a  short 
time  impacted,  and  the  immediate  injury  to  the  bowel  is  only 
slight,  removal  should  be  followed  by  complete  and  permanent 
relief.  If  on  the  other  hand  the  impaction  is  prolonged,  many 
complications  may  arise,  dependent  upon  the  nature  of  the 
agent  and  its  effect  upon  the  bowel  wall.     Thus  inflammation, 

'  St.  Bartholomnv' s  Hospital  Bcports,  1891,  vol.  xxvii.  p.  58. 


FOREIGN   RODIES-CON'CRETIOXS  r,7r, 

ulceration,  or  sloughing  may  occur,  with  possibly  later  perfora- 
tion. Should  these  proce.'ses  take  place  in  the  upper  part  of 
the  rectum,  the  peritoneum  may  become  involved,  and  then 
either  a  local  peritonitis  set  up,  with  possibly  abscess  forma- 
tion ;  or  a  more  general  peritonitis  may  arise  and  prove  fatal. 

When  ulceration  takes  place  nearer  the  anal  extremity 
of  the  gut,  a  perirectal  abscess  may  form,  and  bursting  ex- 
ternally somewhere  in  the  perineum,  give  rise  to  one  of  the 
forms  of  fistula  in  ano.  Fistulous  communications  may  also 
be  formed  between  the  bladder  or  urethra  in  the  male,  and 
the  uterus  or  vagina  in  the  female. 

In  cases  of  less  extensive  injury  to  the  bowel  wall,  such 
for  instance  as  more  frequently  occurs  when  fteces  are 
impacted  or  the  foreign  bodies  pass  into  the  bowel  from 
above,  the  mucous  membrane  becomes  inflamed  from  the 
constant  irritation  to  which  it  is  subjected.  In  some  cases 
this  irritation  leads  to  nothing  more  than  a  slight  catarrhal 
inflammation ;  in  others,  however,  its  severity  causes  the 
condition  to  be  almost  dysenteric  in  character.  Such  was  tlie 
case  in  the  illustration  given  below,  where  the  patient  was 
at  first  supposed  to  be  suffering  from  an  attack  of  acute 
dysentery. 

When  the  rectum  is  completely  blocked  by  the  impacted 
mass,  so  that  flatus  cannot  pass,  symptoms  of  acute  intestinal 
obstruction  set  in,  less  in  severity  as  a  rule  than  in  cases  of 
obstruction  higher  up  the  bowel. 

Treatment. — In  almost  all  cases  of  foreign  bodies  in  the 
rectum,  whether  introduced  from  below  through  the  anus  or 
descended  from  above,  mechanical  measures  alone  are  of 
service  in  effecting  removal.  When  within  reach  of  the  finger, 
a  careful  examination  should  be  first  made  to  ascertain  the 
nature  and  situation  of  the  obstructing  agent.  If  it  be  found 
too  large  to  be  easily  withdrawn,  the  anus  should  be  dilated, 
so  as  to  avoid  any  undue  laceration  of  the  parts.  Should 
difficulty  still  exist,  a  free  incision  may  be  carried  through 
the  sphincter  backward  towards  the  coccyx.  By  traction  and 
rotatory  movements,  exercised  either  with  the  fingers  or  with 
forceps,  most  obstacles  can  be  removed. 

In  cases  where  the  '  body  '  has  been  forced  up  beyond  the 
reach  of  the  finger,  much  difficulty  may  be  encountered  in 


676  THE   RECTUM 

attempting  its  withdrawal.  If  extraction  cannot  be  effected 
by  a  long  pair  of  forceps,  the  surgeon  is  forced  to  the  ultimate 
resource  of  sigmoidotomy,  as  jpi'actised  by  Spanton  in  the 
ease  recorded  above. 

When  the  rectum  is  obstructed  by  hard  faeces,  or  foreign 
bodies  which  have  passed  into  it  from  above,  the  finger  is 
frequently  capable  of  breaking  down  the  mass  and  dislodging 
it  by  fragments.  Failing  the  finger,  a  scoop  or  spoon  will 
usually  prove  successful. 

If  there  is  reason  to  fear  that  the  rectum  has  already 
suffered  injury,  either  from  the  prolonged  retention  of  the 
foreign  body  or  from  the  special  nature  of  the  impacting 
agent,  or  perchance  during  the  process  of  removal,  every  care  ■ 
must  be  taken  to  give  the  parts  rest.  The  patient  should  be 
confined  to  bed,  mild  aperients  administered  to  keep  the 
motions  soft,  and  in  some  cases  the  bowel  washed  out  with 
warm  water.  All  complications  must  be  treated  on  general 
surgical  principles. 

Case  CIII. — Impaction  of  seeds,  fruit  stones,  and  husJcs  in  the  rect^im  : 
acute  proctitis  :  removal.  Recovery. 
A  boy  aged  10  j^ears  had  suffered  for  some  days  from  what  was  sup- 
posed to  be  a  severe  attack  of  dysentery.  "When  received  into  hospital 
on  the  eighth  day  of  his  illness,  he  was  compelled  to  go  to  stool  every 
half-hour.  He  passed  very  small  quantities  at  a  time,  not  much  more 
than  a  teaspoonful.  The  evacuations  were  very  offensive,  yellowish, 
slimy,  and  tmged  with  blood.  Defecation  caused  much  pain,  and  was 
accompanied  with  involuntary  evacuation  of  urine.  In  appearance  he  was 
in  a  wretchedly  depressed  condition,  with  sunken  eyes  and  a  heavy  facial 
expression.  His  pulse  was  weak,  his  tongue  furred,  and  his  breath  very 
fetid.  In  any  movement  of  his  body  the  abdominal  muscles  were  ren- 
dered rigid.  The  skin  about  the  anus  was  very  much  reddened  and 
excoriated,  while  the  anus  itself  gaped  to  the  extent  of  a  one-  or  two- 
shilling  piece;  hanging  from  the  margin  of  the  orifice  were  shreds  of 
tissue.  When,  in  the  course  of  treatment  of  the  supposed  dysentery,  an 
endeavour  was  made  to  wash  out  the  bowel,  it  was  found  that  the  catheter 
would  only  enter  a  short  distance.  The  finger  also  could  enter  no  further, 
but  a  pointed  body  was  felt  which  when  extracted  with  a  pair  of  forceps 
proved  to  be  black  seeds.  Other  endeavours  were  then  made,  and  about 
half  a  cupful  of  seeds  and  husks  was  removed.  It  was  noted  that  the 
pointed  ends  of  some  of  the  seeds  and  husks  stuck  into  the  mucous  mem- 
brane. The  seeds,  which  the  boy  on  seeing  confessed  to  have  eaten, proved 
to  be  those  of  the  sunflower.  On  the  two  following  days,  washing  out 
the  rectum  brought  away  more  than  a  cupful  of  the  seeds.      The  bo}' 


PROCTITIS  577 

remained  in  much  the  same  state :  tenesmus  with  the  passage  of  sHmy 
yellowish  stools.  Two  clays  later,  masses  of  necrotic  tissue  were  passed, 
and  the  motions  also  contained  purulent  matter.  From  this  period 
onward,  however,  he  gradually  improved,  and  eventually  quite  recovered. 
(Goerne,  '  Bei-liner  klin.  Wochenschrift,'  1891,  vol.  xxviii.  p.  34.) 


CHAPTER    LXXI 


DISEASE.       INFLAMMATION  :     PROCTITIS,  PERIPROCTITIS. 
NON-MALIGNANT    ULCERATION 

In  discussing  diseases  of  the  rectum,  it  is  only  intended  to 
deal  with  such  as  involve  the  strictly  intestinal  portion  of  the 
canal.  Hence  such  affections  as  heemorrhoids,  Jfistula  in  ano, 
fissure,  and  anal  ulcer,  which  implicate  the  anus  and  an  inch 
or  so  of  the  bowel  above  it,  do  not  come  within  the  scope  of 
the  present  work. 

The  diseases  to  be  considered  are  inflammation,  ulcera- 
tion, non-malignant  stricture,  carcinoma  and  sarcoma,  innocent 
tumours,  prolapse,  neuroses,  malformations,  and  conditions 
dependent  upon  external  influences. 

Inflammation. — Involvement  of  the  bowel  wall  alone,  con- 
stitutes proctitis,  w^hile  implication  of  the  tissues  around  it  is 
termed  periproctitis. 

Proctitis.— The  inflammatory  action  may  be  acufe  or 
chronic,  local  or  general.  In  the  acute  form  the  mildest 
manifestation  is  that  of  a  simple  catarrh  of  the  mucous  mem- 
brane, while  its  severest  type  is  met  with  in  some  of  the  more 
virulent  cases  of  dysentery.  The  disease  may  arise  from 
some  local  irritation  or  from  infection.  In  the  former  case  it 
may  be  the  result  of  injury,  of  foreign  bodies,  intestinal 
worms,  faecal  accumulation,  or  it  may  be  due  to  the  adminis- 
tration of  drastic  purgatives  either  by  the  mouth  or  by  injec- 
tion. In  a  case  reported  by  Gibbs,'  severe  proctitis  resulted 
from  the  injection  of  pure  carbolic  acid  into  internal  haemor- 
rhoids. Not  infrequently  some  inflammation  exists  in  cases 
of  stricture,  whether  simple  or  malignant,  and  in  polypus. 

Inflammation  the  result  of  infection  arises  from  gonor- 
rhoea, diphtheria,  and  erysipelas.     In  these  cases  the  virus  is 

'  New  YurJ:  Med.  Journ.  1892,  vol.  Ivi.  p.  93.  ■ 

P  P 


578  THE   RECTUM 

usually  carried  to  the  part  either  by  extension  from  the 
vaoina  in  the  case  of  the  female,  or  by  direct  introduction 
from  without.  In  t'le  case  of  gonorrhoea  it  has  been  known 
to  follow  sodomy. 

Dysentery  constitutes  a  disease  of  itself,  and  often  impli- 
cates some  portion  of  the  colon  as  well  as  the  rectum. 

Symptoms. — ^In  its  mildest  form  inflammation  of  the  rec- 
tum is  recognised  by  a  reddened  and  swollen  condition  of  the 
mucous  membrane,  which  sometimes  protrudes  from  the 
anus.  Tenesmus  is  frequently  present,  and  mucus  in  variable 
quantity  is  passed,  sometimes  alone,  at  other  times  mixed 
with  the  faeces.  The  condition  of  the  bowels  varies,  sometimes 
being  constipated,  at  other  times  relaxed.  Some  degree  of 
pain  is  usually  felt  in  the  rectum,  and  this  may  radiate  to  the 
back  and  down  the  limbs. 

The  more  acute  the  inflammatory  process  the  more 
prominent  become  these  symptoms.  Instead  of  mucus  in 
the  evacuations,  they  may  contain  pus  and  blood  ;  the  pain 
assumes  more  of  a  burning  character.  Digital  examination 
causes  considerable  pain,  while  the  finger  detects  a  heated 
and  swollen  state  of  the  mucous  membrane.  In  addition  to 
these  local  symptoms  there  may  be  more  or  less  constitutional 
disturbance.  The  patient  will  be  feverish,  with  loss  of  ap- 
petite, loss  of  sleep,  and  other  disturbances  dependent  upon 
these  conditions. 

The  constant  discharge  of  mucus  and  inflammatory  pro- 
ducts from  the  rectum  is  liable  to  produce  an  inflamed,  excori- 
ated, and  painful  condition  of  the  anus  and  the  skin  around. 
In  some  cases  there  is  frequency  of  micturition,  due  to  the 
reflex  irritation  of  the  bladder. 

In  the  severest  form  of  acute  proctitis — that  due  to 
dysentery — there  is  more  disturbance,  both  constitutionally 
and  locally,  than  is  usually  met  with  in  inflammation  arising 
from  other  causes.  The  disease  should  be  studied  in  works 
on  medicine,  where  it  finds  a  more  fitting  place  for  discussion 
than  in  a  work  on  surgery. 

Prolonged  acute  inflammation  may  lead  to  grave  secondary 
lesions,  such  as  ulceration,  perirectal  inflammation,  abscess, 
and  peritonitis. 

Chronic,  j'roctitis  may  either  exist  as  such  from  the  outset, 


1'K()(;TTT1S  579 

or  it  may  follow  upon  an  acute  attack.  The  symptoms  are 
much  less  severe,  and  consist  chiefly  in  the  discharge  of 
mucus  with  the  motions,  which  as  a  rule  are  rather  solid 
than  loose,  and  are  passed  infrequently.  Prolonged  inflam- 
mation may  lead  to  contraction  of  the  calihre  of  the  canal, 
and  this  may  finally  end  in  ulceration  or  stricture. 

Treatment. — Attention  must  be  directed  in  the  first  place 
to  the  cause  of  the  condition.  When  this  is  of  a  removable 
nature,  all  symptoms  may  rapidly  subside  on  its  being  effi- 
ciently dealt  with.  Should,  however,  the  inflammation  con- 
tinue, both  local  and  general  measures  must  be  adopted.  The 
patient  should  be  confined  to  bed,  and  placed  upon  a  diet  of 
a  bland  and  simple  kind.  Mild  laxatives  should  be  adminis- 
tered if  there  is  a  tendency  to  constipation.  Hot  hip-baths 
may  relieve  the  pain  and  also  lessen  the  congestion.  If  local 
applications  are  considered  requisite,  water  as  warm  as  can 
be  borne  should  be  injected,  and  the  addition  of  a  few  drops 
of  laudanum  will  assist  in  producing  a  soothing  effect.  In 
chronic  cases  astringents  such  as  alum  and  tannin  should  be 
injected. 

The  treatment  of  dysentery  hardly  calls  for  any  remarks 
by  the  surgeon,  and  would  not  be  mentioned  here  were  it  not 
for  the  fact  that  it,  like  chronic  membranous  or  ulcerative 
colitis,  has  in  recent  years  yielded  to  the  surgeon's  opera- 
tive measures  where  the  physician's  therapeutic  efforts  have 
failed.  At  a  meeting  of  the  Clinical  Society  of  London  in 
December  1895,  Godlee  '  mentioned  a  case  of  dysentery  in 
which  much  improvement  had  followed  upon  opening  the 
colon.  The  rationale  of  such  treatment  exists  in  the  complete 
rest  afforded  the  inflamed  and  ulcerated  mucous  membrane 
by  the  temporary  diversion  of  the  f^ces  through  an  artificial 
anus.  As  illustrating  a  case  of  severe  proctitis,  the  one  re- 
ported under  the  heading  of  '  Foreign  bodies  '  serves  as  a  good 
example  (see  p.  576).  The  following  equally  well  illustrates 
the  same  disease,  due,  however,  to  another  cause. 

Case  ClY.—Actite  proctitis  the  result  of  tahing  large  doses  of  imtent 
cathartic  remedies. 
A  woman  aged  23  years  had  always  been  constipated,  and  for  years 
had  been  in  the  habit  of  using  purgatives  wlienever  she  desired  an  evacua- 

'  Brit.  Med.  Journ.  1895,  vol.  ii.  p.  1559. 

p  p  2 


680  THE   RECTUM 

tion.  For  the  past  six  months  she  noticed  occasional  discharge  of  blood 
and  slime  from  the  rectum,  wliich  was  constantly  increasing.  She  now 
suffered  great  pain  on  defecation,  and  the  amount  of  blood  and  muco- 
purulent material  increased  to  such  an  extent  that,  while  at  first  it  only 
came  when  at  stool,  it  had  subsequently  been  coming  several  times  a 
day.  She  suffered  pain  in  the  rectum  at  all  times.  Her  general  condition 
was  poor ;  she  had  lost  her  appetite,  and  was  unable  to  sleep. 

A  careful  examination  of  the  rectum  showed  it  to  be  congested,  hot 
and  painful  as  far  as  the  eye  could  see.  The  amount  of  discharge  sug- 
gested gonorrhoea  of  the  rectum,  but  there  was  no  inflammation  of  the 
vagina,  and  no  reason  from  the  history  of  the  case  to  suspect  it.  The  real 
cause  appeared  to  be  in  the  habit  which  she  had  contracted  of  taking 
large  doses  of  patent  cathartic  remedies  two  or  three  times  a  week  in 
order  to  overcome  her  chronic  constipation.  (Charles  B.  Kelsey, '  Diseases 
of  the  Rectum  and  Anus,'  1883,  p.  67.) 

Periproctitis. — Inflammation  of  the  tissues  around  the 
rectum  occasionally  arises  as  an  extension  from  inflammation 
of  the  rectum  itself ;  as  often,  however,  it  owes  its  origin  to 
some  cause  situated  without  the  rectum.  It  may  be  local  or 
general — in  other  words,  it  may  consist  in  the  formation  of  a 
circumscribed  abscess,  or  in  an  acute  cellulitis  involving  a 
considerable  extent  of  the  perirectal  tissue. 

The  localised  or  circumscribed  form  of  periproctitis  fre- 
quently owes  its  origin  to  the  extension  of  a  perforative  ulcera- 
tion. This  ulceration  may  result  from  injury,  direct  or 
as  the  result  of  a  foreign  body,  to  stricture,  or  to  any  of  those 
causes  which  will  be  found  more  fully  described  under  the 
heading  of  *  Ulceration.'  The  situation  of  the  inflammatory 
focus  is  important  as  bearing  upon  the  possible  complica- 
tions which  may  arise.  Thus,  when  located  below  the 
levator  ani,  the  abscess  may  burst  in  one  or  more  places  on 
the  perineal  surface ;  and  should  a  communication  also  be 
formed  with  the  rectum,  one  form  of  fistula  in  ano  would 
result.  On  the  other  hand,  with  an  abscess  arising  above  the 
levator  ani,  a  rupture  might  take  place  into  the  bladder  or 
the  peritoneal  cavity. 

A  form  of  periproctitis,  described  as  gangrenous,  is  occasion- 
ally met  with  in  men  addicted  to  good  living  and  free  drinking. 
The  inflammation  is  of  a  severe  type,  and  involves  consider- 
able necrosis  of  cellular  tissue  around  the  lower  part  of  the 
rectum.  Both  ischio-rectal  fossae  are  infiltrated  with  inflam- 
matory products ;  the  skin  around  the  anus  becomes  reddened 


PERIPROCTITIS  681 

and  almost  livid  in  appearance  ;  there  is  much  pain,  and  the 
patient  usually  suffers  from  fever  and  other  constitutional  dis- 
turbances. The  treatment  consists  in  free  and  deep  incisions 
into  the  ischio-rectal  fossfe. 

In  other  eases  of  localised  or  general  periproctitis,  efforts 
should  be  made  to  prevent  the  advance  of  the  inflammation 
to  suppuration  by  the  injection  of  hot  water  and  the 
administration  of  laxatives.  When  it  is  to  be  feared  that 
suppuration  is  commencing,  the  bowel  wall  should  be  in- 
cised, and  relief  thus  afforded  to  the  congested  and  inflamed 
area. 

Non-malignant  ulceration.^ — In  the  majority  of  instances 
ulceration  is  the  sequel  to  inflammation,  and  may  therefore 
be  met  with  in  the  later  stage  of  all  those  inflammatory 
affections  which  have  just  been  described.  These  causes, 
briefly  recapitulated,  are  injury,  either  direct  or  from  the 
presence  of  foreign  bodies,  faecal  retention  or  impaction, 
drastic  purgatives,  chronic  diarrhoea  in  children,  polypus, 
stricture,  dysentery,  gonorrhoea,  and  diphtheria.  In  addition 
to  these  must  be  added  ulcers  resulting  from  tuberculosis, 
syphilis,  varicose  veins,  and  from  special  causes  arising 
without  the  bowel,  such  as  those  connected  with  parturition 
and  vaginal  affections. 

Non-malignant  ulceration  is  much  more  frequently  met 
with  in  women  than  in  men.  In  Poelchen's^  series  of  219 
cases,  to  which  reference  will  again  be  made,  190  were  women, 
25  men,  2  children,  and  2  in  which  the  sex  is  not  given. 
This  author  assigns  as  one  reason  for  this  greater  frequency  of 
ulceration  in  women,  the  common  occurrence  of  recto-vaginal 
fistula.  Thus  in  the  above  list  of  190  cases  recto-vaginal 
fistula  was  found  present  in  46. 

While  it  is  possible  to  enumerate  the  various  probable 
causes  of  ulceration,  it  is  by  no  means  so  easy  to  ascribe  to 
any  particular  lesion  its  true  cause.  In  cases  where  there  is 
a  definite  history  of  injury,  disease,  or  previous  inflammation 
of  some  recognised  kind,  little  difficulty  exists  in  determining 
the  cause ;  but  these  cases  may  be  said  to  constitute  the 
minority.  In  the  large  proportion  of  cases  no  definite 
predisposing   or   exciting   cause   is   ascertainable ;    and    the 

'  Archiv  filr  path.  Anat.  unci  Phys.  1892,  vol.  cxxvii   p.  189. 


582  THE   RECTUM 

somewhat  uiireasonable  custom  in  the  past  has  been  to 
ascribe  these  otherwise  inexpHcable  ulcers  to  syphiHs.  The 
tendency,  however,  of  modern  surgeons  is  to  find  other 
explanations  of  their  existence,  and  not  to  relegate  to  syphilitic 
a,ction  that  which  cannot  be  ascribed  to  anything  else,  and 
which  has  not,  in  many  cases,  even  the  evidence  or  history 
of  the  constitutional  disease  to  support  it. 

Ulceration  of  the  rectum  presents  features  very  much  the 
same,  no  matter  what  the  cause.  It  may  be  so  slight  that  it 
consists  of  little  more  than  a  superficial  erosion  of  the  mucous 
membrane.  While  on  the  other  hand  it  may  extend  so 
deeply  as  to  cause  perforation  of  the  bowel  wall  and  establish 
communications  with  the  tissues  and  parts  around.  Again, 
the  ulcers  may  be  single  or  multiple,  and  vary  in  size  from  a 
small  point,  as  in  the  follicular  ulcer  of  infantile  diarrhoea,  to 
involvement  of  almost  the  entire  bowel  wall,  as  is  sometimes 
seen  in  dysentery  and  in  slowly  progressive  chronic  ulceration 
(see  Plate  XXVI,  fig.  99).  The  character  of  the  ulcer  also 
varies  according  to  its  acuteness  or  chronicity,  such  variations 
being  indicated  by  the  amount  of  induration  or  vascularity  of 
its  base  and  edges.  The  tendency  which  most  ulcers  of  the 
rectum  have  to  spread  and  coalesce  naturally  gives  rise  to 
considerable  variation,  dependent  upon  the  stage  at  which 
the  process  has  arrived,  or,  in  other  words,  the  time  during 
which  it  has  been  going  on. 

Among  the  ulcerative  processes  which  call  for  a  more 
detailed  description  are  the  dysenteric,  the  tubercular,  the 
syphilitic,  the  varicose,  and  those  dependent  upon  special 
causes,  such  as  parturition  and  vaginal  inflammation. 

Dysenteric  ulceration. — As  most  frequently  met  with  in  mild 
cases,  the  initial  inflammatory  process  gives  rise  to  follicular 
ulceration,  so  that  the  bowel  surface  presents  numerous  small 
ulcers,  at  first  superficial  and  discrete,  but  later  becoming 
deeper  and  confluent.  In  the  severer  types  of  the  disease, 
large  ulcers  result  from  the  necrosis  of  patches  of  mucous 
membrane,  due  to  the  detachment  of  the  part  by  extravasated 
blood.  Such  extensive  and  deep  ulceration  leads  sometimes 
to  perforation,  with  all  the  consequences  dependent  upon 
abscess  formation  and  fistula.  Asa  feature  somewhat  distinc- 
tive of  this  kind  of  ulceration  in  its  acute  stage,  the  mucous 


PLATE    XXVI. 


Fig.  yg.— Extensive  Chronic  Ulceration  of  the  Entire  Rectum.— .i.  Healed 
cicatricial  part  situated  just  within  the  anus  ;  b.  the  margins  of  the  ulcer 
formed  of  normal  mucous  membrane ;  c.  islets  of  mucous  membrane 
situated  in  the  base  of  the  ulcer.     {y.I.M.,  Ghn.) 


ULCERATION  583 

membrane  around  the  centres  of  necrosis  is  frequently  acutely 
intlamed  and  much  swollen. 

As  the  disease  subsides,  the  acute  inflammatory  process 
also  diminishes,  and  the  rectum  then  presents  the  more 
typical  characters  of  limited  and  uncomplicated  ulceration. 
It  is  in  this  condition  that  the  disease  is  most  frequently 
presented  to  the  surgeon ;  and  which,  in  the  process  of 
healing,  may  give  rise  to  one  of  the  forms  of  non-malignant 
stricture. 

Case  CY.— Dysenteric  ulceration  of  the  rectum,. 
A  child  aged  5  years  had  suffered  from  attacks  of  dysentery  for  more 
than  a  year.  For  two  months  previous  to  admission  into  hospital,  it  had 
had  from  two  to  four  bloody  movements  each  day.  On  examination  with 
the  speculum,  the  whole  mucous  membrane  was  fovmd  congested.  Just 
inside  the  sphincter  there  were  many  small  ulcers,  and  situated  from 
three  to  five  inches  from  the  anus  there  were  several  large  ones,  measur- 
ing two  inches  in  length  and  half  an  inch  in  width.  He  was  put  on 
sterilised  milk,  and  given  three  grains  of  citrate  of  iron  and  quinine,  three 
times  daily.  The  rectum  was  irrigated  four  times  daily  with  a  saturated 
solution  of  boracic  acid,  and  a  suppository  of  iodoform  gr.  ii  and  sub- 
nitrate  of  bismuth  gr.  v  inserted  after  each  irrigation.  Rest  in  bed.  With 
some  other  slight  variations  in  the  treatment,  the  child  made  a  good 
recovery  in  the  course  of  three  months.  (Acker,  '  Archives  of  Pediatrics,' 
1892,  voh  ix.  p.  438.) 

Tubercular  ulceration. — The  process  by  which  the  rectum 
becomes  involved  in  tubercular  disease  differs  in  no  respect 
from  that  which  occurs  in  other  parts  of  the  intestinal  canal. 
As  in  these  also,  the  disease  is  usually  a  concomitant  of 
disease  elsewhere,  most  frequently  of  pulmonary  phthisis. 

The  process  commences  by  the  deposition  of  tubercle  in 
and  beneath  the  mucous  membrane  ;  these  deposits  caseate 
and  break  down,  and  when  several  are  in  close  apposition,  the 
result  is  an  irregular  destruction  of  tissue,  with  the  formation 
of  an  ulcer. 

The  ulcers  follow  the  usual  type  of  tubercular  ulceration 
elsewhere ;  the  edges  are  frequently  thin  and  undermined ; 
the  surface  is  more  or  less  smooth  and  glazed  in  appearance ; 
the  outline  is  irregular,  and  the  tendency  of  the  ulcer  is  to 
extend  both  superficially  and  deeply.  If  the  bowel  wall  is 
perforated,  abscess  may  result,  and  this  bursting  into  some 
other  part  may  lead  to  complications  similar  to  those  already 


584  THE   RECTUM 

alluded  to  as  liable  to  result  from  all  perforative  processes  of 
ulceration. 

In  and  around  the  ulcer,  nodules  are  often  seen.  These 
are  deposits  of  tubercle,  and  constitute  one  of  the  typical 
features  of  the  ulceration. 

The  usual  course  of  the  disease  is  to  progress ;  when,  how- 
ever, healing  takes  place,  stricture  may  follow  as  the  result 
of  the  repair. 

Case  CVI. — Tubercular  ulceration  of  the  rectum:  phthisis. 
A  man  aged  about  40  years  complained  of  discharging  some  mucus 
each  day,  accompanied  by  a  good  deal  of  tenesmus,  but  with  no  pain. 
On  examination  of  the  rectum  a  distinct  ulcer  was  found,  beginning  just 
above  the  sphincter  and  extending  u])wards.  It  was  somewhat  conical 
in  shape,  the  base  being  below.  It  had  the  peculiar  characteristics  of  a 
tubercular  ulcer.  There  was  no  pus.  The  base  was  a  glairy,  palish  red. 
There  were  no  well-defined  edges,  although  the  ulcer  had  some  depth. 
No  particular  pain  was  noticed  when  it  was  touched.  The  treatment 
advised  was  the  application  of  stimulating  lotion  to  the  ulcer,  and  strict 
attention  to  cleanliness  and  the  patient's  general  health.  There  were 
marked  symptoms  of  pulmonary  phthisis  present.  (Mathews,  '  Diseases 
of  the  Rectum  and  Anus,'  p.  325.) 

Syphilitic  ulceration. — The  frequency  with  which  syphilitic 
ulceration  occurs  is  probably  much  less  than  was  at  one  time 
supposed.  The  tendency  to  ascribe  to  syphilis  all  ulceration 
which  could  not  be  accounted  for  in  any  other  way,  is  as 
unreasonable  as  it  is  erroneous.  The  absence  of  any 
specific  history  should  in  the  majority  of  instances  as 
certainly  exclude  syphilis  in  the  role  of  causes  as  the  absence 
of  a  history  of  dysentery  would  be  considered  sufficient  to 
exclude  that  disease.  And  the  additional  fact  that  any  ulcer 
is  not  affected  by  antisyphilitic  treatment,  should  render  even 
the  suspicion  of  a  specific  taint  untenable. 

That  ulceration  may  result  from  syphilis  is  another  ques- 
tion, and  one  which  most  surgeons  would  answer  in  the 
affirmative.  It  invariably  arises  from  the  breaking  down  of 
gummata  deposited  in  the  submucous  tissue.  It  occurs  as  a 
late  and  tertiary  lesion  of  the  disease.  The  breaking  down 
of  a  gumma  gives  rise  to  a  circular  ulcer  with  sharply  defined 
margins  and  a  vascular  base.  When  two  or  more  deposits 
coalesce,  the  ulcer  becomes  irregular  in  outline  and  uneven 
on  its    surface.      As  in  the  tubercular    form  of   ulceration. 


ULCERATION  585 

the  (lestrnction  of  tissue  may  extend  deeply  and  give  rise  to 
the  same  train  of  coraphcations.  Cicatrisation  of  an  extensive 
ulcer  may  lead  to  one  of  the  forms  of  rectal  stenosis.  (See 
Syphilitic  Stricture.) 

Another  way  in  which  the  rectum  may  be  affected  hy  ulcera- 
tion is  from  the  extension  of  specific  sores  and  ulcers  which 
originate  around  the  anus. 

Varicose  ulcer.- — It  is  reasonable  to  suppose,  and  there  is 
evidence  to  show,  that  simple  ulcer  may  form  in  the  rectum 
as  the  result  of  a  congested  condition  of  the  mucous  membrane 
from  varicose  veins,  just  as  the  same  kind  of  lesion  arises  from 
varicose  veins  in  the  leg.  The  only  exciting  cause  necessary 
to  start  the  process  is  some  slight  abrasion ;  and  this  is 
readily  enough  found  in  hardened  and  retained  faeces.  Gibbs,* 
who  has  devoted  considerable  attention  to  this  kind  of  ulcera- 
tion, states  that  in  nine  out  of  ten  cases  the  ulcer  involves 
only  a  small  area,  from  the  size  of  a  thumb  nail  to  that  of  a 
'  silver  quarter.'  Most  frequently  they  are  situated  posteriorly, 
and  from  one  to  two  inches  from  the  anus.  The  muscular 
coat  is  seldom  penetrated.  The  diagnostic  features  of  this 
kind  of  ulcer  are  :  (1)  The  lack  of  any  tangible  or  definite 
cause ;  (2)  their  occurrence  in  otherwise  healthy  persons  ; 
(3)  their  extreme  chronicity  ;  (4)  their  amenability  to  proper 
treatment ;  and  (5)  the  frequently  marked  evidence  of 
haemorrhoids.  The  special  treatment  advised,  beside  that 
usually  adopted  in  all  cases  of  rectal  ulceration,  is  to  make  a 
longitudinal  incision  through  the  base  of  the  ulcer,  deep  enough 
to  sever  the  underlying  circular  muscular  layers.  This  cut  is 
to  be  continued  through  the  anus  with  the  object  of  securing 
drainage  and  preventing  inflammation  in  the  tissues  around. 

Case  CVII. — Simple  ulcer  of  tlie  rectum  due  to  varicose  veins. 
A  gentleman  aged  35  years  had  suffered  intermittently,  and  more  or 
less  severely,  with  pain  of  a  dtill  aching  character,  coming  on  after  defe- 
cation. A  discharge  of  pus  and  hlood  was  noticed,  and  was  always  most 
marked  in  the  morning.  When  a  rectal  examination  was  made,  an  ulcer 
about  the  size  of  a  quarter-dollar  was  found  two  inches  from  the  anus. 
The  ulcer  appeared  healthy,  not  deep  or  punched  out,  and  had  no  overhang- 
ing edges.     The  granulations  were  soft  and  bled  on  touch.     There  was  no 

'  New  York  Med.  Joiirn.  1892,  vol.  hi.  p.  93. 


586  THE   RECTUM 

assignable  caiiee.  Syphilis  could  be  absolutely  excluded,  and  the  general 
health  was  unusually  robust.  His  condition  had  been  stationary  for  years, 
and  showed  no  tendency  to  improve.  By  special  care,  however,  complete 
cicatrisation  of  the  iilcer  occurred  in  three  months.  (John  Blair  Gibbs, 
'  New  York  Med.  Journ.'  1892,  vol.  Ivi.  p.  93.) 

Ulceration  from  other  causes. — There  are  two  other  causes 
of  ulceration  m  the  -rectum,  which  serve,  to  some  extent,  to 
explain  the  greater  frequency  of  the  condition  in  women. 
One  occurs  as  the  result  of  parturition,  and  the  other  from 
inflammaiion  of  Bartholin's  glands.  In  the  former  case  the 
ulceration  results  from  the  destruction  of  tissue  in  the  upper 
part  of  the  rectum,  caused  by  its  being  unduly  pressed  upon, 
or  perchance  lacerated  in  the  passage  of  the  foetal  head  through 
the  pelvic  cavity. 

Ulceration  secondary  to  inflammation  of  Bartholin's 
glands  is  a  theory  propounded  by  Poelchen,  and  has  been 
carefully  worked  out  in  the  paper  already  referred  to.  The 
theory  is  that  inflammation  and  suppuration  of  these  glands 
lead  to  perforation  of  the  rectum  and  ulceration,  the  im- 
mediate result  being  the  formation  of  a  recto-vaginal  fistula. 
In  this  way,  he  believes,  is  to  be  explained  the  large  proportion 
(46  out  of  190)  of  recto-vaginal  fistulse  met  with  in  his  series 
of  cases. 

Symptoms. — So  graphically  does  William  Allingham  de- 
scribe the  symptoms  of  rectal  ulceration,  that  I  venture  to 
give  a  complete  abstract  from  his  work  on  '  Diseases  of 
the  Eectum.'  ^ 

'  In  the  majority  of  these  cases  the  earliest  symptom  is 
morning  diarrhoea,  and  that  of  a  peculiar  character  ;  in  my 
opinion  it  is  quite  indicative  of  the  disease,  and  can  be  con- 
founded only  with  similar  symptoms  due  to  cancer.  The 
patient  will  tell  you  that  the  instant  he  gets  out  of  bed  he 
feels  a  most  urgent  desire  to  go  to  stool ;  he  does  so,  but  the 
result  is  not  satisfactory.  What  he  passes  is  generally  wind, 
a  little  loose  motion,  and  some  discharge  resembling  "  coflee 
grounds "  both  in  colour  and  consistency ;  occasionally  the 
discharge  is  like  the  white  of  egg;  or  a  "jelly  fish;  "  more 
rarely  there  is  matter.  The  patient  in  all  probability  has 
tenesmus  and  does  not  feel  relieved  ;  there  is  a  burning,  some- 

'  4th  edit.  p.  226. 


ULCEIJATJON  687 

what  uncomfortable  sensation,  but  not  actual  pain ;  before  he 
is  dressed  he  very  likely  has  again  to  seek  the  closet ;  this 
time  he  pasfes  more  motion,  often  lumpy  and  occasionally 
smeared  with  blood.  It  may  also  often  happen  that  after 
breakfast,  hot  tea  or  coffee  having  been  taken,  the  bowel  will 
again  act ;  after  this  he  feels  all  right,  and  goes  about  his 
business  for  the  rest  of  the  day,  only  perhaps  being  occasion- 
ally reminded  by  a  disagreeable  sensation  that  he  has  some- 
thing wrong  with  his  bowel.  Not  by  any  means  always,  but 
at  times,  the  morning  diarrhoea  is  attended  with  griping  pain 
across  the  lower  part  of  the  abdomen,  and  great  flatulent 
distension.  When  a  medical  man  is  consulted  the  case  is, 
in  all  probability,  and  quite  excusably,  considered  one  of 
diarrhcea  of  a  dysenteric  character  and  treated  with  some 
stomachic  and  opiate  mixture,  which  affords  temporary  relief. 
After  this  condition  has  lasted  for  some  months,  the  length  of 
this  period  of  comparative  quiescence  being  influenced  by  the 
seat  of  the  ulceration  and  the  rapidity  of  its  extension,  the 
patient  begins  to  have  more  burning  pain  after  an  evacuation, 
there  is  also  greater  straining,  and  an  increase  in  the  quantity 
of  discharge  from  the  bowel ;  there  is  now  not  so  much  jelly- 
like matter,  but  more  pus — more  of  the  coftee-ground  dis- 
charge and  blood.  The  pain  suffered  is  not  very  acute,  but 
very  wearying ;  described  as  like  a  dull  toothache,  and  it  is 
induced  by  much  standing  about  and  walking.  At  this 
stage  of  the  complaint  the  diarrhoea  comes  on  in  the  evening 
as  well  as  the  morning,  and  the  patient's  health  begins  to 
give  way,  only  triflingly  so,  perhaps,  but  he  is  dyspeptic,  loses 
his  appetite,  and  has  pain  in  the  rectum  during  the  night, 
which  disturbs  his  rest ;  he  also  has  wandering  and  apparently 
anomalous  pains  in  the  back,  hips,  down  the  leg,  and  some- 
times in  the  penis.  There  is  yet  another  symptom  present  in 
the  later  stages,  marking  the  existence  of  some  slight  con- 
traction of  the  bowel,  viz.  alternating  attacks  of  diarrhoea  and 
constipation,  and  during  the  attacks  of  diarrhoea,  the  patient 
passes  a  very  large  quantity  of  fseces.  These  seizures  are 
attended  with  severe  colicky  pains  in  the  abdomen,  faintness, 
and  not  infrequently  sickness. 

'  On  examining  these  cases  of  ulceration,  various  conditions 
may  be  noticed  according  to  the  stage  to  which  the  disease 


,588  THE   RECTUM 

has  advanced.  In  the  earher  period  you  may  often  feel  an 
ulcer  situated  dorsally  about  an  inch  and  a  half  from  the 
anus,  oval  in  form,  perhaps  an  inch  long  by  half  an  inch  wide, 
surrounded  by  a  raised  and  sometimes  hard  edge ;  there  is 
acute  pain  caused  on  touching  it,  and  it  may  be  readily  made 
to  bleed.  "With  a  sjpeculum  you  can  distinctly  see  the  ulcer, 
the  edges  well  marked,  the  base  greyish  or  very  red  and 
inflamed-looldng,  the  surrounding  mucous  membrane  being 
probably  healthy  ;  in  the  neighbourhood  of  the  ulcer  may 
often  be  felt  some  lumps,  which  are  either  gummata  or  enlarged 
rectal  glands.  This  is  the  stage  in  which  the  disease  is  often 
curable.  .  .  .  Later  in  the  progress  of  the  malady  you  will 
observe  deep  ulcers  with  great  thickening  of  the  mucous 
membrane,  often  also  roughening  to  a  considerable  extent,  as 
though  the  mucous  membrane  had  been  stripped  off.  At 
this  stage  you  generally  notice,  outside  the  anus,  swollen  and 
tender  flaps  of  skin,  shiny,  and  covered  with  an  ichorous 
discharge;  these  flaps  are  commonly  club-shaped,  and  are 
met  with  also  in  malignant  disease  ;  but  in  the  early  develop- 
ment of  the  disease  710  ulceration  is  found  near  the  anus  nor  at 
the  aperture.  ...  So  definite  is  this  external  appearance  in 
long-standing  disease,  that  one  glance  is  sufficient  to  enable 
an  expert  to  predicate  the  existence  of  either  cancer  or  severe 
ulceration  ;  these  external  enlargements  are  the  result  of  the 
ulceration  going  on  in  the  bowel,  and  the  irritation  caused  by 
almost  constant  discharge.' 

The  imperceptible  way  in  which  severe  ulceration  may 
pass  on  to  stricture  produces  a  train  of  symptoms  which 
gradually  point  more  prominently  to  the  existence  of  the  latter 
than  to  that  of  the  former.  It  must  further  be  remembered 
that,  as  ulceration  proceeds,  symptoms  may  appear,  due  not 
directly  to  the  ulcer  nor  to  the  resulting  stricture,  but  to 
other  complications,  to  which  either  has  given  origin. 

Treatment. — In  most  cases  both  local  and  constitutional 
treatment  is  required.  As  regards  constitutional,  this  has 
reference  more  particularly  to  tubercular  and  syphilitic  ulcera- 
tion, and  the  special  remedies  and  measures  usually  employed 
in  these  diseases  must  be  used. 

As  regards  the  treatment  of  the  ulcer,  the  patient  should 
be  kept  as  much  as  possible  in  the  recumbent  position,  with 


ULCERATION— TlfEA'I'.M  1:NT  589 

the  bed  or  couch  raised  at  the  foot,  so  as  to  relieve  the  con- 
gestion of  the  bowel. 

Where  there  is  a  tendency  to  constipation,  laxatives  should 
be  administered. 

When  it  is  necessary  to  deal  directly  with  the  ulcer,  either 
stimulants,  astringents,  or  sedative  applications  may  he  re- 
quired. 

When  the  ulcer,  from  its  chronicity  or  sluggishness,  needs 
stimulating,  hot  water  may  be  injected ;  or,  as  Mathews ' 
recommends,  pure  carbolic  acid  can  be  applied.  In  using  the 
latter,  care  must  be  taken  to  guard  the  skin  and  mucous 
membrane  around.  The  insufflation  of  iodoform  is  also  strongly 
recommended  by  the  same  author. 

To  produce  an  astringent  effect,  a  solution  of  nitrate  of 
silver,  two  grains  to  the  ounce  or  stronger,  may  be  applied. 
When  much  pain  exists,  either  opium  or  cocaine  may  be  used. 
Cripps  ^  recommends  an  ounce  of  warm  thin  starch  containing 
twenty  drops  of  liquor  opii  sedativi  injected  by  a  soft  tube 
well  ujD  the  bowel  after  it  has  been  previously  washed  out  with 
warm  water.  Cooper  and  Edwards^  recommend  the  apj)]ica- 
tion  of  cocaine  ointment ;  twenty  grains  to  the  ounce. 

Operative  measures. — The  simplest  operation  is  that  of 
scraping  or  scarifying.  In  some  instances  scraping  is  con- 
sidered advisable  in  tubercular  ulceration  ;  as  a  rule,  however, 
this  kind  of  ulcer  increases  or  diminishes  according  to  the 
general  state  of  the  patient.  If  the  phthisical  condition, 
which  is  usually  present,  improves,  the  ulcer  does  so  also, 
and  vice  versa,  and  to  scrape  under  these  circumstances  may 
not  better  matters.  Scarification  is  best  employed  when  the 
ulcer  presents  indurated  edges  and  shows  an  indisposition 
to  heal. 

In  cases  of  inflamed  and  irritable  ulceration,  great  relief  is 
afforded  by  division  of  the  external  sphincter,  the  ulcer  gains 
greater  rest,  and  freedom  from  irritation. 

Severer  operative  measures  consist  in  excising  the  ulcer 
or  a  part  of  the  rectum,  or  in  making  a  temporary  artificial 
anus  in  the  sigmoid  flexure.     Lange  ^  reports  having  success- 


Page  332.  2  Page  196.  a  Page  109. 

*  Annals  of  Surgery,  1893,  vol.  xvii.  p.  325. 


590  THE   RECTUM 

fully  excised  the  entire  rectum,  by  the  posterior  incision,  in  a 
case  of  syphilitic  ulceration  involving  the  whole  inner  surface 
of  the  bowel. 


CHAPTEE   LXXII 

NON-MALIGNANT    OR    CICATRICIAL    STRICTURE 

No  disease  of  the  rectum  offers  greater  difficulties  on  certain 
etiological  and  pathological  points  than  non-mahgnant  stric- 
ture. That  stricture  may  result  either  from  cicatrisation  of 
an  ulcer,  or  from  inflammation  of  the  rectal  walls,  or  from 
inflammation  arising  primarily  outside  the  bowel,  is  sufficiently 
certain  ;  but  the  difficulty  arises  when  the  question  becomes 
one  of  determining  in  any  particuJar  and  doubtful  case  which 
of  these  processes  has  led  to  the  contraction.  Before  dis- 
cussing these  points  more  fully,  there  are  other  features  worthy 
of  notice  regarding  the  age  and  sex  of  the  patients  usually 
affected. 

In  analysing  a  table  of  seventy  cases  of  stricture  of  the 
rectum  recorded  by  Allingham,  sixty  were  females  and  ten 
males.  This  is  somewhat  under  the  relative  proportion  given 
by  other  statisticians.  Thus  Poelchen,  out  of  219  cases  of 
strictures  forming  ulcers,  records  190  as  occurring  in  females, 
while  the  sex  in  four  out  of  the  remaining  twenty-nine  cases  is 
not  given. 

As  regards  age,  by  far  the  largest  proportion  occur  between 
the  years  of  20  and  40.  Fifty-six  of  Alhngham's  cases  ' 
occurred  during  this  period  ;  while  eleven  were  over  40  years, 
the  oldest  being  80 ;  and  only  three  were  under  20,  the 
youngest  being  13. 

The  kind  of  stricture  met  with  varies.  In  the  larger  pro- 
portion of  the  cases  the  stenosed  part  is  either  amiular  or 
tubular — that  is  to  say,  the  canal  is  obstructed  either  by  a 
rino--shaped  constriction,  or  it  is  more  or  less  uniformly 
narrowed  for  some  distance.  In  cases  of  cicatricial  stricture 
following  ulceration,  the  nature  of  the  stenosis  necessarily 
depends  upon  the  shape  and  extent,  both  superficially  and 
deeply,  of  the  tissue  destroyed.  Strictures  so  formed  may 
'  Diseases  of  tlic  Rectum  and  Anus,  p.  230. 


CICATIMCIAL    STlIKTl'in-:  591 

exist  in  the  Bliapc  of  a  diaphragm,  or  as  bands  crossing  in 
various  directions. 

Stricture  as  a  sequel  to  ulceration  owes  its  origin  indirectly 
to  the  various  caused  which  give  rise  to  the  latter.  These 
have  been  discussed  already,  and  need  only  be  briefly  enu- 
merated here.  They  are  traumatism,  which  may  be  taken 
to  include  direct  injuries,  impaction  of  foreign  bodies  or 
hardened  faces,  operations  by  the  surgeon,  and  injury  occur- 
ring during  parturition  ;  syphilis,  tuberculosis,  dysentery,  and 
varicose  veins.  While  these  causes  are  all  enumerated,  it 
must  not  be  understood  that  they  imply  in  any  sense  a  uniform 
frequency  of  occurrence.  Rather  should  they  be  looked  upon 
as  possible  causes  among  which  syphilis,  tuberculosis,  and 
dysentery  probably  account  for  the  larger  proportion. 

When  the  stricture  partakes  of  the  tubular  character,  its 
origin  may  be  the  result  of  cicatrisation  after  ulceration,  but 
it  seems  more  probable  that  it  is  a  sequel  to  acute  or  chronic 
proctitis.  The  walls  of  the  bowel,  especial!}^  the  submucous 
and  muscular  coats,  become  infiltrated  wdth  inflammatory 
material,  which  in  organising  and  contracting  produces  a 
rigid  and  resisting  fibrous  canal.  It  is  the  etiology  of  this 
particular  kind  of  stricture  which  has  been  the  subject  of  so 
much  controversy  in  past  years.  The  old  custom  of  ascribing 
it  to  syphilis,  whether  there  existed  other  evidences  of  the 
disease  or  not,  has  frequently  been  called  in  question.  Not 
only  is  the  stricture  met  with  in  cases  where  there  is  not 
the  least  evidence  of,  or  any  reason  to  suspect,  syphilis,  but 
the  lesion  itself  has  no  similarity  to  specific  affections  in  any 
other  part  of  the  body.  That  syphilis  plays  some  important 
part  in  the  formation  of  rectal  stricture  is  acknowledged  and 
sufficiently  attested  by  all  statistics.  Thus  out  of  Allingham's 
seventy  cases,  thirty-five  suffered  from  undeniable  constitu- 
tional syphilis,  and  other  five  had  some  symptom  of  it, 
making  a  percentage  of  50.  This  ratio,  however,  is  some- 
what in  excess  of  that  given  by  others.  Thus  in  Poelchen's 
series  of  219  cases  there  was  a  history  of  syphilis  in  nirety- 
six,  making  a  percentage  of  43-3 ;  while  Cooper  and  Edwards 
give  the  average  as  from  25  to  30  per  cent. 

Difficulty,  however,  is  encountered  when  an  attempt  is 
made  to  define  the  nature  of  the  initial  lesion  eausins  this 


592  THE   RECTUM 

form  of  tubular  stenosis.  By  some  it  is  believed  to  be  due  to 
the  healing  of  a  broken-down  gumma,  against  which  view, 
however,  it  is  contended  that  the  natural  process  of  cure  in  a 
disintegrated  gumma  is  not  by  a  contracting  cicatrix,  but  by 
atrophic  changes  in  the  tissues  concerned.  Others  believe 
that  in  the  late  stage  of  the  disease  an  infiltration  of  the 
muscular  coat  with  small  round  cells  takes  place.  These,  by 
organising,  lead  to  the  formation  of  fibrous  tissue,  which,  in 
contracting,  causes  atrophy  of  the  muscular  fibres  and  a 
narrowing  and  induration  of  the  canal.  To  discuss  this  inte- 
resting subject  further,  would  carry  me  beyond  the  limits  of 
the  space  at  my  disposal.  Those  therefore  who  would  like 
to  pursue  it,  I  would  recommend  to  consult  such  an  excellent 
authority  as  Kelsey,  who  has  devoted  much  thought  and 
attention  to  it. 

Among  external  causes  which  give  rise  to  stricture,  the 
injury  resulting  from  parturition  occupies  a  prominent  jDlace. 
Its  influence  m  producing  injury,  sometimes  of  an  extensive 
and  serious  kind,  has  been  mentioned  already. 

Pathological  sequences. — The  results  accruing  from  stricture 
of  the  rectum  are  much  the  same  as  those  occurring  in 
stricture  in  other  parts  of  the  intestinal  canal,  modified  only 
by  the  anatomical  relations  of  the  region.  One  of  the 
earliest  changes  to  take  place  as  the  canal  narrows  is 
its  dilatation  above  the  obstruction.  This  is  accompanied 
also  with  some  hypertrophy  of  the  muscular  coat  and 
thickening  of  the  mucous  membrane.  As  the  dilatation 
advances,  its  presence  may  become  manifest  by  a  generally 
distended  condition  of  the  abdomen.  The  irritation  to  which 
the  mucous  membrane  above  the  stricture  is  exposed  by  the 
retained  faeces  leads  to  a  variable  amount  of  inflammation  and 
ulceration.  This  process  may  extend  to  the  peritoneum  and 
cause  a  chronic  form  of  localised  peritonitis  ;  or,  if  ulceration 
advances,  abscess  in  the  surrounding  tissues  may  form  and 
burst  either  into  the  rectum  below  the  stricture,  or  find  its 
way  into  the  ischio-rectal  fossa,  where,  by  opening  externally, 
it  gives  rise  to  one  form  of  fistula  in  ano.  Communication 
may  also  be  estabhshed  between  the  vagina,  uterus,  bladder, 
or  urethra  from  the  ulceration  advancing,  or  the  abscess 
bursting,  into  these  parts. 


CICATRICIAL    STRICTURE  593 

Below  the  sti-icture,  changes  are  also  met  with  in  the  bowel 
wall.  It  is  frequently  noted  that  the  cavity  of  the  bowel  is 
unusually  large,  this  condition  being  technically  described  as 
'  ballooning.'  The  mucous  membrane  is  often  ulcerated  and 
the  haemorrhoidal  veins  distended.  The  nearer  the  stricture 
is  to  the  anus,  the  more  is  the  anal  aperture  likely  to  be 
involved  in  other  changes.  In  severe  cases  it  becomes  patu- 
lous, with  protrusion  of  the  mucous  membrane  from  the  orifice, 
which  sometimes  amounts  to  actual  prolapse  of  the  bowel. 
The  frequent  discharge  of  purulent  material  causes  trouble- 
some eczematous  eruptions  and  excoriations  of  the  skin  around 
the  anus. 

Symptoms. — In  cases  of  stricture  following  ulceration, 
there  is  usually  the  history  of  symptoms  of  variable  duration 
and  severity  connected  with  the  latter ;  and  when  stricture 
is  the  result  of  such  constitutional  affections  as  tuberculosis, 
syphilis,  and  dysentery,  there  is  also  either  existing  or  past 
evidence  of  such  diseases. 

The  lesion  itself,  when  at  a  more  or  less  advanced  stage, 
usually  gives  rise  to  a  fairly  typical  train  of  symptoms.  One 
of  the  earliest  and  most  troublesome  of  these  is  that  con- 
nected with  the  increasing  obstruction  to  the  normal  passage 
of  the  faeces.  The  patient  finds  that  he  is  unable  to  get  a 
movement  of  the  bowel  without  taking  an  aperient.  This 
perpetual  retention  of  the  faeces  above  the  constricted  part 
soon  gives  rise  to  additional  troubles.  The  irritation  of  the 
mucous  membrane  causes  inflammation  and  ulceration,  with 
a  frequent  discharge  of  blood  and  pus.  The  patient  is  thus 
frequently  induced  to  go  to  stool,  but  the  straining  efforts 
induced  lead  to  little  more  than  the  ejection  of  the  inflam- 
matory exudation.  When  faeces  are  passed,  they  may  be  in 
small  fragments,  scybalous,  flattened,  or  attenuated,  their 
conformation  depending  principally  upon  the  tightness  and 
situation  of  the  stricture.  Thus,  when  situated  high  up,  an 
accumulation  may  take  place  ia  the  lower  dilated  portion  of 
the  rectum,  before  evacuation  follows. 

The  more  persistent  and  obstructive  the  disease  the 
severer  become  the  symptoms,  both  general  and  local.  The 
patient  suffers  from  increasing  distension  of  the  abdomen, 
due  to  the  accumulation  of  faeces  within  the  colon  and  to  the 

Q  Q 


594  THE   RECTUM 

development  of  flatus.  The  stomach  becomes  deranged,  so  that 
there  is  often  nausea  and  distaste  for  food.  Emaciation  soon 
follows,  with  pallor  of  skin  and  derangement  of  the  nervous 
system ;  the  latter  showing  itself  in  sleeplessness  and  mental 
depression.  Without  relief,  the  patient  dies  of  exhaustion 
unless  carried  off  by  some  intercurrent  complication,  such  as 
acute  intestinal  obstruction  or  peritonitis. 

The  amount  of  pain  suffered  varies.  When  severe  it  is 
felt  not  only  in  the  part,  but  at  the  back  of  the  sacral  region, 
in  the  abdomen,  and  down  the  thighs-  As  complications 
appear,  such  as  abscess  formation,  feverish  symptoms  arise, 
which  more  or  less  disappear  on  the  bursting  or  evacuation  of 
the  purulent  collection  ;  other  symptoms,  however,  may  then 
arise  dependent  upon  the  creation  of  fistulous  communica- 
tions either  with  the  exterior  of  the  body,  or  with  some  viscus 
internally.  The  onset  of  acute  intestinal  obstruction  or 
acute  peritonitis  will  be  indicated  by  the  symptoms  usually 
significant  of  those  conditions. 

Diagnosis. — While  the  symptoms  narrated  above  may  lead 
to  a  strong  suspicion  of  stricture,  it  is  not  until  a  careful 
examination  has  been  carried  out  either  by  the  finger  or  the 
bougie  that  a  certain  diagnosis  can  be  made. 

For  all  strictures  situated  within  the  lower  four  inches  of  the 
rectum,  digital  examination  is  sufficient ;  but  for  those  higher 
up,  one  of  three  means  must  be  adopted :  either  the  whole 
hand  must  be  inserted,  or  the  rectum  be  distended  with  fluid, 
or  a  bougie  passed. 

For  using  the  hand  for  purposes  of  diagnosis,  see  p.  566. 
Injections  are  sometimes  serviceable  when  conducted  in  con- 
junction with  auscultation  and  palpation  of  the  sigmoid  flexure. 
The  observation  is  conducted  with  the  object  of  determining 
the  quantity  of  fluid  which  can  be  injected,  and  whether  or 
not  it  passes  upwards  into  the  large  intestine.  The  method 
is  helpful,  but  not  certain,  since  it  is  open  to  the  objection 
that  the  fluid  may  pass  through  the  stricture  and  so  mislead. 
The  bougie,  next  to  the  hand,  affords  the  most  reliable 
information.  It  has,  however,  to  be  used  with  care;  and 
is  open  to  the  objection  that  it  may  mislead  by  being  ob- 
structed in  its  course  by  a  fold  of  mucous  membrane,  or  by 
impinging  upon  the  sacrum. 


CICATRICIAL   STRICTURE 


595 


Three  kinds  of  bougies  are  used,  both  for  purposes  of 
diagnosis  and  for  treatment.  These  are  represented  by 
figs.  100-102. 

Of  these,  the  one  with  the  oHve-shaped  ivory  head  and 
flexible  shaft  is  best  for  diagnostic  purposes.  Not  only  does 
it  render  certain  the  existence  of  a  stricture,  but  it  affords  a 


O 


O 


Fig.  100.— Eound- 
SHAPED  Bougie 


Fig.  101 Conical- 
shaped  Bougie 


Fig.  102.  — Olive-shaped 

IVOBY-HEAD    BoUGIE 


Figs.  100-102. — Kect-^l  Bougies.     About  half  natural  size 


means  of  determining  its  length.  When  the  '  olive  '  has 
passed  through  the  stricture,  the  shaft  is  felt  to  slip  easily 
backwards  and  forwards ;  but  on  withdrawal,  it  is  at  once 
detected  when  the  '  olive  '  re-enters  the  proximal  part  of  the 
obstruction,  and  the  grip  remains  obvious  until  it  is  dis- 
engaged and  enters  the  dilated  bowel  below.  For  directions 
regarding  the  passage  of   bougies,  see  Operations  upon  the 


o96  THE   PtECTUM 

Eectum  (Chapter  LXXXII) .  It  may  be  incidentally  noted  here 
that  the  use  of  a  bougie  for  diagnostic  purposes  must  always 
be  gone  about  with  great  care,  as  the  bowel  wall  may  be 
injured  to  the  extent  even  of  fatal  perforation. 

The  true  nature  of  a  stricture  as  to  its  resistance  and 
resiliency  can  only  be  ascertained  by  the  finger.  In  very 
tight  and  hard  strictures  it  is  impossible  sometimes  to  insert 
even  the  tip  of  the  finger,  much  less  to  be  able  to  pass  it 
through. 

As  a  further  mechanical  aid  to  diagnosis,  the  speculum 
may  be  used. 

One  symptom  which  has  been  mentioned,  and  which  is 
considered  of  special  value  in  the  diagnosis  of  stricture  high 
up,  is  that  of  so-called  '  ballooning  of  the  rectum.'  The 
condition  of  expansion  or  dilatation  of  the  bowel  below  the 
stricture  has  long  been  recognised,  but  it  is  due  to  Thomas 
Bryant  ^  more  particularly  that  it  has  come  to  occupy  a 
recognised  place  among  the  important  symptoms.  By 
Bryant  the  condition  is  considered  almost  pathognomonic 
of  stenosis,  either  innocent  or  malignant,  which  has  been  of 
slow  and  not  rapid  formation.  The  dilatation  is  supposed  to 
be  primarily  due  to  a  partial  paralysis  of  the  muscular  coat, 
induced  by  the  interference  with  normal  peristalsis  by  the 
stricture ;  and  secondarily  to  distension  of  the  part  by  gas 
and  faeces. 

This  symptom,  however,  cannot,  in  the  light  which  further 
investigation  has  thrown  upon  it,  be  considered  exclusively 
distinctive  of  this  kind  of  disease.  Burghard,^  out  of  an 
examination  of  200  patients,  found  ballooning  of  the  rectum 
to  exist  under  three  different  circumstances.  First,  in  cases 
of  stricture  of  the  rectum  and  sigmoid  flexure ;  second,  in 
chronic  constipation  and  fsecal  obstruction ;  and  third,  in 
spinal  disease.  It  was  never  found  when  the  stricture  was 
situated  above  the  lower  end  of  the  descending  colon. 

Prognosis. — Stricture  of  the  rectum  is  incurable,  in  the 
sense  that,  while  a  patient  may  be  relieved  for  a  variable 
period,  the  tendency  to  recurrence  remains  a  possibility 
throughout  life.  If  any  exceptions  can  be  found  to  this  rule, 
they  are   among   those   cases  which   have   been   treated  by 

'  Lancet,  1889,  vol.  i.  p.  8.  -  Ibid.  1890,  vol.  ii.  p.  92. 


CICATRICIAL    STRICTURE  597 

successful  excision  or  by  linear  proctotomy.  The  most  intract- 
able forms  to  deal  with  are  those  where  the  bowel  is  uniformly 
contracted  for  a  considerable  extent.  Belief  may  always 
be  temporarily,  if  not  permanently,  afforded ;  but  only  at 
the  expense  of  sacrificing  the  natural  ways  of  defecation  for 
artificial. 

In  slighter  cases  the  regular  and  intermittent  use  of 
bougies  may  maintain  a  normal  passage  for  an  indefinite 
period,  the  patient  in  many  cases  being  able  to  enjoy  life 
for  so  long  as  it  lasts.  No  kind  of  stricture  is  amenable  to 
•curative  treatment  other  than  that  which  may  be  considered 
of  an  operative  character. 

Case  CVIII. — Non-malignant  stricture  of  the  rectum  :  linear 
proctotomy.  Recovery. 
A  man  aged  23  years  had  suffered  from  syphilis  for  five  years ;  he 
was  pallid  and  emaciated,  and  complained  of  the  greatest  difficulty  in 
defecation.  He  had  a  continuous  discharge  of  bloody  mucus  from  the 
anus.  Digital  examination  showed  a  ring  of  ulceration  round  the  entire 
circumference  of  the  gut,  most  marked  in  front,  and  immediately  above 
the  ulcerated  surface  a  tight  stricture  was  to  be  felt;  the  tip  of  the  index 
finger  would  not  pass  into  it,  and  it  felt  hard  and  rigid.  Attempts  to 
dilate  with  bougies  gave  rise  to  great  irritation,  and  rather  aggravated  his 
condition.  His  abdomen  became  distended,  and  he  had  some  vomiting. 
Linear  proctotomy  was  performed.  The  relief  of  the  symptoms  was  im- 
mediate, and  a  good  recovery  followed.  When  seen  eighteen  months 
after  the  operation,  his  defecation  was  normal,  except  that  a  slight  amount 
of  incontinence  occurred  when  he  had  an  attack  of  diarrhoea.  There  was 
no  indication  of  any  recurrence  of  the  stricture,  and  he  was  quite  strong 
in  health.  (Charles  B.  Ball,  '  Trans,  of  the  Royal  Academy  of  Medicine 
in  Ireland,'  1889,  vol.  vii.  p.  184.) 

Treatment. — Independently  of  treatment  applied  directly 
to  the  stricture,  much  relief  may  be  afforded,  especially  in 
the  earlier  stages  of  the  disease,  by  careful  attention  to  the 
diet  and  the  condition  of  the  bowels.  Food  of  a  rich  and 
indigestible  nature  is  liable  to  prove  irritating  to  the  bowel ; 
a  diet  therefore  as  simple  and  nutritious  as  possible  should 
be  given. 

To  keep  the  motions  loose  a  mild  laxative  should  be 
administered,  and  when  much  difficulty  exists  in  obtaining  a 
movement,  a  slowly  introduced  enema  may  effect  the  desired 
result. 

All  measures,  however,  to  deal  with  the  stricture,  or  with 


598 


THE   RECTUM 


tlie  obstruction  to  which  it  has  given  rise,  must  be  of  an 
operative  nature.     The  following  methods  are  employed  : 

1.  Dilatation  by  bougies,  tents,  and 
dilators. 

2.  Electrolysis. 
-    3.  Internal  proctotomy. 

4.  External  or  linear  proctotomy. 

5.  Proctectomy. 

6.  Inguinal  or  lumbar  anus. 

The  selection  of  any  one  of  these  me- 
thods depends  entirely  upon  the  nature  of 
the  stricture  and  the  surgeon's  aim  in  treat- 
ing it. 

1.  Treatment  by  bougies. — Only  stric- 
tures of  a  limited  and  not  very  severe 
type  can  be  thus  treated.  The  dilatation 
is  effected  by  the  daily,  or  less  frequent, 
passage  of  bougies  of  increasing  calibre. 
The  good  obtained  is  only  temporary, 
and  to  be  of  any  permanent  value,  must 
be  continued  indefinitely  at  variable  inter- 
vals, determined  chiefly  by  the  tendency 
Avhich  the  stricture  shows  to  contract. 
(For  passage  of  bougies,  see  Operations 
upon  the  Kectum,  Chapter  LXXXIII.) 

The  good  effects  exercised  by  the  pres- 
sure of  a  bougie  retained  for  some  time 
within  the  stricture  has  induced  Crede ' 
to  devise  a  shape  which  could  be  kept 
in  position  with  a  minimum  degree  of 
discomfort  to  the  patient.  The  instrument 
is  shown  in  fig.  103.  It  is  made  in  four 
sizes.  Its  chief  advantage  is  supposed  to 
be  in  the  narrowness  of  the  part  which  rests 
within  the  anus,  thus  causing  less  dilata- 
tion and  consequently  less  discomfort  and 
pain.      The  bougies   can    be   retained  for 


Fig.      103.  —  Crede's 
Eectal  Bougie. 

Natural  size,  No.  20 


Arcliiv  filr  klin.  Chir.  1892,  vol.  xliii.  p.  175. 


CICATrJCIAL   STRICTURE  .599 

periods  varying  from  half  an  hour  to  several  hours,  once  or 
twice  daily. 

2.  Treatment  by  electroli/sis. — The  success  vs^hich  first 
attended  the  treatment  of  urethral  stricture  hy  electrolysis 
led  to  its  employment  in  rectal  disease.  It  has  not,  how- 
ever, heen  so  uniformly  successful  that  the  treatment  has 
received  any  very  large  or  general  application.  Isolated 
cases  of  cure  are  recorded.  Thus  Whitmore  ^  is  reported  to 
have  had  admirable  results  in  relieving  several  cases  which 
had  been  more  or  less  intractable  to  the  ordinary  methods  of 
dilatation.  In  one  of  these  cases  the  time  taken  for  treatment 
extended  over  three  months.  In  a  case  reported  by  Earle,^ 
a  stricture,  which  would  only  admit  a  silver  x^robe,  had  existed 
for  several  years  ;  it  had  been  unsuccessfully  treated  by  linear 
proctotomy,  but  yielded  to  treatment  by  electrolysis.  The 
cathode  of  a  galvanic  battery  was  placed  within  the  stricture, 
while  the  anode  was  placed  upon  the  abdomen.  The  treat- 
ment occupied  eight  sittings,  at  one  week  apart,  and  for 
fifteen  minutes  at  each  sitting.  At  the  end  of  the  period  a 
bougie  could  be  passed  which  was  two  inches  in  circumference. 

Eobert  Newman,^  with  an  experience  of  fourteen  cases 
treated  by  electrolysis,  '  found  that  the  best  results  in  the 
treatment  of  rectal  strictures  were  obtained  from  the  use  of 
the  same  method  as  would  be  employed  in  the  treatment  of 
urethral  strictures,  except  that  a  stronger  current  may  be 
used,  and  the  sittings  may  be  more  frequent.  While  in  the 
urethra  5  milliamperes  would  be  sufficient,  15  milliamperes 
may  be  used  in  the  rectum.  The  treatment  may  last  fifteen 
or  twenty  minutes,  and  the  sitting  should  be  once  in  every  four 
days.' 

B.  Treatment  hy  internal  jproctotomy. — The  division  of  a 
stricture  from  within  has  its  advocates,  and  has  had  its 
successes ;  but  the  operation  has  always  one  serious  danger. 
The  incision  into  the  tissues  allows  of  the  septic  infection 
of  the  wound  by  the  faeces,  and  this  may  lead  to  trouble- 
some inflammatory  complications.  In  place  of  one  incision 
right  through  the  stricture,  it  is  sometimes  cut  in  more  than 
one  place.     The  treatment  necessitates  for  its  completion  the 

'  Annual  of  the  Universal  Medical  Sciences,  1888,  vol.  v.  p.  61. 
-  Ibid.  1881),  vol.  V.  D-1-1.  ''  Ibid.  1891,  vol.  v.  C-2r,. 


600  THE   RECTUM 

subsequent  passage  of  bougies,  which  must  be  continued  in- 
definitely if  recontraction  is  to  be  prevented. 

4.  Treatment  by  external  or  linear  iiroctotomy. — This  opera- 
tion consists  in  entire  division  of  the  stricture  and  all  the 
parts,  including  the  sphincters,  from  the  tip  of  the  coccyx 
backwards  and  downwards.  It  is  employed  in  cases  of  severe 
tubular  stricture,  where  the  question  becomes  one  of  attempting 
excision  or  making  an  artificial  anus.  The  great  advantages 
of  this  operation  are  the  immediate  relief  given  to  all  obstruc- 
tive symptoms,  and  the  complete  drainage  afforded.  As 
regards  results  of  the  operation,  it  probably  affords  the  nearest 
approach  of  any  method  to  a  complete  cure.  Some  cases  will 
not  succeed  without  the  subsequent  employment  of  the  bougie, 
and  even  with  this  failure  occasionally  occurs.  In  speaking 
of  a  cure,  no  case  should  be  considered  as  such  unless  two 
years  at  least  of  freedom  from  obstruction  have  elapsed  since 
the  operation. 

5.  Treatment  by  excision. — While  this  is  the  most  serious 
of  all  the  operations,  it  at  least  aims  at  being  radical.  Its 
two  great  risks,  which  almost  amount  to  prohibitive  objec- 
tions, are  that  should  union  by  granulation  of  the  divided 
ends  of  the  bowel  take  place,  there  is  still  the  grave  possibility 
of  another  stricture  forming  as  the  result  of  the  operation  ;  and 
should  union  prove  still  less  satisfactory,  serious  inflamma- 
tory complications  may  arise,  or  troublesome  fgecal  fistulse 
result.  By  some,  however,  a  sacral  anus  is  considered  even 
preferable  to  an  inguinal  or  lumbar  one.  When  there  is 
reason  to  believe  that  the  bowel  is  much  dilated  above  the 
stricture,  the  formation  of  a  temporary  artificial  anus  in  the 
groin  will  serve  the  double  purpose  of  giving  the  distended 
portion  some  little  time  to  contract  before  attempting  excision, 
and  remove  the  irritating  and  septic  effect  of  the  passage  of 
the  faeces  past  the  line  of  union  after  the  operation.  When 
primary  union  of  the  divided  ends  takes  place,  a  practically 
ideal  result  is  obtained. 

Herczel  ^    removed    a  syphilitic    stricture   measuring   7^ 

ctms.  in  length.     Owing  to  sudden  collapse  of  the  patient, 

the    operation  had  to  be  hurriedly   concluded   by   stitching 

the  proximal  end  to  the  skin,  thus  forming  a  sacral  anus. 

*  Wiener  med.  Wochenschrift,  1892,  vol.  xlii.  p.  1081. 


TUMOURS  fiOl 

The  case  did  \\e\\,  and  the  patient  was  dismissed  from  the 
hospital  two  months  after  the  operation,  free  from  pain  and 
with  one  normal  daily  evacuation.  This  author  refers  to  two 
other  cases  of  excision  by  the  sacral  method  by  Richelot  and 
Terrier,  where  an  excellent  result  was  obtained. 

6.  Artificial  anus. — This  is  formed  either  in  the  left 
inguinal  or  left  lumbar  region.  When  symptoms  of  acute 
obstruction  are  present,  the  operation  becomes  an  imperative 
one  ;  but,  short  of  such  acuteness,  the  choice  of  treatment 
usually  lies  between  this  operation  and  external  proctotomy. 

With  an  artificial  anus  the  patient  must  be  prepared  to 
go  through  the  rest  of  his  life  with  the  inconvenience  neces- 
sarily attached  to  such  an  outlet.  With  proper  regulation  of 
the  bowels,  however,  and  due  attention  to  cleanhness,  it  is 
possible  to  reduce  the  discomforts  to  a  minimum  ;  and  it  is 
asserted  by  such  experienced  surgeons  as  Thomas  Bryant, 
William  Allingham,  and  Kelsey,  who  favour  and  frequently 
practise  the  operation,  that  not  only  is  the  immediate  relief 
great,  but  the  patient's  future  life  may  be  one  of  perfect  com- 
fort and  enjoyment.  There  is  this  advantage  about  an  arti- 
ficial anus,  that  it  carries  the  assurance  that  so  far  as  the 
stricture  is  concerned,  and  the  kind  of  suffering  which  the 
patient  has  endured,  there  need  be  no  more  trouble  or  anxiety. 


CHAPTEE   LXXIII 

TUMOURS  :    INNOCENT.       POLYPUS 


The  rectum  is  liable  to  be  the  seat  of  various  kinds  of  inno- 
cent tumours,  which  vary  in  their  relative  frequency.  While 
differing  in  structure  and  in  the  tissues  from  which  they 
take  their  origin,  there  is  a  remarkable  uniformity  in  the 
shape  and  form  which  they  sooner  or  later  assume.  With 
very  few  excerptions  a  tumour  developing  in  or  from  the  wall 
of  the  rectum  soon  becomes  a  more  or  less  pedunculated 
growth  projecting  into  the  bowel  and  attached  to  it  by  a 
pedicle  which  may  be  long  and  narrow,  or  short  and  broad. 
This  peculiar  feature,  which  has  caused  these  growths  to  be 
generically  spoken  of  as  polypi,  probably  owes  its  origin  to  the 
mechanical  effect  of  an  intermittent  vis  a  tergo.     Every  time 


602  THE   EECTUM 

defecation  takes  place,  the  growth  is  pressed  upon  from  above 
by  the  descendmg  soHd  matters  ;  and  when  once  this  effect  has 
been  produced,  it  doubtless  becomes  added  to  by  the  natural 
expulsive  efforts  of  the  bowel  to  rid  itself  of  what  it  interprets 
as  the  presence  of  foreign  matter. 

There  is  another- feature  worthy  of  note  in  connection  with 
these  so-called  innocent  tumours,  and  that  is,  that  the  line  of 
separation  between  them  and  malignant  growths  is  not  always 
a  very  clear  and  decided  one.  The  subject  will  be  alluded  to 
again,  when  discussing  particular  forms  of  the  disease ;  but  the 
fact  is  referred  to  here,  so  that  the  preliminary  assumption 
may  not  be  made  that  every  tumour  now  to  be  described  is 
necessarily  of  a  purely  innocent  nature — that  is  to  say,  that 
its  removal  necessarily  implies  its  non-recurrence  and  non- 
extension. 

The  innocent  tumours  met  with  in  the  rectum  are  adeno- 
mata, fibromata,  ijapilloviata,  lymjjhomata,  myomata,  myxomata, 
lipomata,  cystomata,  teratomata,  and  angeiomata. 

Adenomata. — By  far  the  largest  number  of  innocent 
tumours  met  with  are  comprised  in  the  class  of  adenomata. 
As  most  frequently  met  with,  they  are  single  tumours,  soft  in 
texture,  vascular,  attached  by  a  narrow  pedicle  to  the  rectal 
wall,  and  occurring  more  often  in  the  young  than  in  adults. 
In  size  they  may  vary  from  a  pea  to  a  walnut,  and  in  one 
typical  form  they  resemble  in  appearance  a  raspberry.  "When 
the  stalk  is  sufficiently  long,  or  the  tumour  is  attached  near 
the  anus,  they  may  project  into  or  through  the  orifice.  When 
examined  microscopically,  they  are  found  to  be  purely  glan- 
dular in  structure,  the  glands  resembling  those  of  other  parts 
of  the  mucous  membrane,  except  that  they  show  much  irregu- 
larity in  their  disposition,  and  considerable  differences  in  size. 
Blood  vessels  pass  through  the  pedicle  to  and  from  the  body 
of  the  tumour ;  and  when  the  arteries  are  of  any  size  their 
pulsation  can  be  easily  felt.  While  this  form  of  polypus  is 
most  frequently  met  with  singly,  exceptional  instances  occur 
where  they  are  disseminated  or  multiple.  These  are  more 
fully  referred  to  below. 

The  extraordinary  resemblance  which  exists  between  the 
microscopic  characters  of  these  so-called  innocent  glandu- 
lar polypi  and  the  malignant  columnar-celled  carcinoma  or 


INNOCENT   TUMOUUS  603 

adenoid  cancers  naturally  raises  the  question  as  to  tlie  pos- 
sibility of  any  connection  existing  between  the  two.  Histolo- 
gically the  one  grows  out  from  the  wall  of  the  bowel,  while  the 
other  grows  into  it ;  but  it  is  probable  that  some  more  cogent 
factor  is  at  work  determining  the  peculiar  invading  features  of 
the  one  than  is  simply  represented  by  what  otherwise  appears 
almost  accidental.  As  bearing  on  this  question  the  following 
facts  are  not  without  interest.  In  a  case  reported  by  Hand- 
ford,  and  already  quoted  in  discussing  innocent  tumours  of 
the  large  intestine,  the  transitional  stages  of  an  adenoid  poly- 
pus to  a  malignant  growth  could  be  well  observed  (see  p. 
462).  In  another  case,  cited  by  Ball,^  a  glandular  polypus 
was  met  with  in  conjunction  with  a  mahgnant  ulcer,  the  one 
being  situated  at  some  distance  from  the  other.  In  a  case  of 
multiple  polypi  recorded  by  T.  Smith,^  a  malignant  stricture 
existed  at  the  junction  of  the  sigmoid  and  rectum. 

Fibromata. — Tumours  of  this  character  are  almost  as 
common  as  those  of  the  preceding  variety.  Together  with 
them  they  may  be  considered  as  constituting  what  is  specifi- 
cally and  commonly  known  as  polypus  of  the  rectum.  In  all 
points  except  in  their  intimate  structure  they  resemble  the 
adenoid  polypus,  being  rounded  in  shape,  and  attached  to  the 
bowel  wall  by  a  pedicle  of  variable  length  and  size.  They 
usually  exist  singly,  but  in  exceptional  instances  are  multiple 
(see  below).  When  examined  microscopically,  they  are  found 
to  consist  of  fibrous  tissue  of  varying  degrees  of  density, 
covered  over  by  normal  mucous  membrane.  A  remarkable 
specimen  was  shown  by  Bowlby  at  the  London  Pathological 
Society,^  of  a  tumour  composed  of  very  loose  connective  tissue. 
It  was  about  the  size  of  a  foetal  head,  and  weighed  two  pounds 
all  but  an  ounce.  It  was  attached  to  the  anterior  wall  of  the 
rectum  of  a  woman  aged  24  years,  at  a  distance  of  about  four 
inches  from  the  anus. 

Papilloma,  or  villous  tumour. — This  form  of  tumour  is  a 
rare  but  well-recognised  and  distinct  type  of  growth.  It 
constitutes  one  of  those  forms  which  occupy  the  boundary 
line   between   what  are  considered  definitely  innocent    and 

'  Trails.  Royal  Academy  of  Medicine  in  Ireland,  1890,  vol.  viii.  p.  414. 
2  St.  Bartholomeiu's  Hospital  Reports,  1887,  vol.  xxiii.  p.  225 
;      3  Trans.  1883,  vol.  xxxiv.  p.  106. 


60 i  THE   RECTUM 

those  that  are  described  as  distinctly  malignant.  For  -while 
the  growth  in  its  initial  state  seems  to  lack  the  features  of 
typical  malignancy  in  not  extending  beyond  its  original  seat, 
it  does  appear  to  resemble  carcinoma  in  occasionally  returning 
after  removal,  and  then  presenting  sometimes  the  character- 
istics of  epithelioma.  William  Allingham,^  whose  clinical 
experience  and  description  of  the  disease  are  at  the  same  time 
the  most  extensive  and  the  best,  says  that  he  is  '  compelled  to 
express  the  opinion  that  they  may  become  malignant,  having 
now  seen  two  cases  in  which  epithelioma  replaced  the  villous 
growth.' 

The  comparative  rarity  of  the  disease  is  shown  in  the 
fact  that  throughout  Allingham's  ^  great  experience,  only 
eight  cases  occurred  in  his  own  practice,  while  he  refers  to  one 
in  the  practice  of  Gowlland,  one  in  Cooper's  practice,  and  two 
under  the  care  of  Goodsall.  Cooper  and  Edwards  ^  give  eight 
cases  as  being  admitted  to  St.  Mark's  Hospital  during  fifteen 
years  ;  seven  were  males,  and  one  a  female.  These  cases, 
however,  probably  include  those  recorded  by  Allingham  ;  but 
Edwards'*  records  at  length  a  case  of  his  own,  where  there 
were  two  tumours,  the  one  pedunculated  and  the  size  of  a 
hen's  egg,  situated  just  inside  the  anus  on  the  anterior  wall  of 
the  gut,  and  the  other  somewhat  smaller,  sessile  and  situated 
higher  up  the  rectum.  Mathews  ^  speaks  of  having  seen  only 
one  case  in  fifteen  years,  but  refers  to  cases  recorded  by  van 
Baren,  Goselin,  Bryant,  and  Cook  in  addition  to  those  quoted 
above.  Cripps  ^  records  in  full  two  cases  seen  by  him. 
Bowlby  ^  reports  a  somewhat  unusual  case  of  a  diffuse  papil- 
lomatous growth,  which  does  not,  however,  appear  to  belong  to 
the  class  here  described.  The  growth  occurred  in  an  Arab 
lad  aged  17  years,  and  was  composed  of  loose  fibrous  tissue, 
rich  in  cells,  apparently  of  inflammatory  origin,  in  the  meshes 
of  which  were  large  numbers  of  the  ova  of  Bilharzia.  Sheild's 
case  recorded  below,  serves  to  illustrate  the  symptoms  usually 
met  with  in  villous  tumours,  although  they  are  possibly  of  a 
somewhat  exaggerated  type. 

The  papillomata  are  frequently  pedunculated,  but  as  fre- 

■  Page  317.  2  p^gg  316.  s  p^ge  247. 

*  Page  251.  ^  Page  515.  «  Page  285. 

''  Trans.  Fath.  Soc.  Loud.  1891,  vol.  xlii.  p.  136. 


INNOCENT   TUMOURS  COo 

quently  sessile.  In  the  former  case  the  peduncle  is  usually 
broader  than  in  the  more  commonly  met  with  adenoid  or 
fibrous  polypus.  In  their  minute  structure  they  resemble  the 
adenomata,  but  present  a  more  irregular  surface  than  the 
latter,  being  '  composed  of  compactly  applied,  various  shapen 
processes,  sometimes  dendritic,  at  others  fiat  and  leafy,  and 
comparatively  simple  in  form'  (Shattock).  They  are  very 
vascular,  and  prone  to  bleed,  large  quantities  of  blood  being 
sometimes  lost.  As  another  distinguishing  feature  from  the 
common  form  of  polypus,  they  are  only  met  with  in  adults, 
and  not  infrequently  in  old  people. 

Case  CIX. — Papilloma  or  villous  tumour  of  the  rectum, 
A  woman  aged  42  j-ears  had  suffered  for  eight  years  with  rectal  sym- 
ptoms. Haemorrhage  was  constant,  so  that  a  condition  of  anaemia  was 
produced  ;  and  sometimes  profuse  bleedings  occmred,  reducing  the 
patient  to  great  prostration.  Abundance  of  offensive  and  tenacious 
mucus  issued  from  the  anus.  The  presence  of  the  growth  impeded 
defecation,  and  it  afterwards  protruded  from  the  anus.  On  several  occa- 
sions it  had  become  strangulated,  causing  much  pain  and  difficulty  of 
reduction. 

In  the  recent  state  the  tumour  was  the  size  of  a  small  orange,  and 
attached  by  a  thick  but  soft  pedicle  of  about  an  in3h  in  length  to  the 
mucous  membrane  of  the  rectum,  about  an  mch  and  a  half  from  the 
anus  on  the  dorsal  aspect  of  the  gut.  It  was  dark  in  colour,  lobulated, 
and  foliaceous  ;  the  surface  soft  and  lacerable,  in  consistence  resembling  in 
appearance  a  portion  of  pancreas  or  salivary  gland.  One  of  the  club-shaped 
processes  was  examined  microscopically,  and  found  to  consist  of  glandular 
and  fibrous  tissue  with  a  covering  of  columnar  epithelium.  (A.  Marmaduke 
Sheild,  '  Trans.  Path.  Soc.  Lond.'  1888,  vol.  xxxis.  p.  130.) 

Multiple  polypi.-- All  three  of  the  preceding  varieties  of 
growths,  as  also  that  of  the  variety  which  immediately  follows, 
may  be  met  with  as  more  or  less  disseminated  or  multiple 
tumours  throughout  the  rectum.  The  two  former,  however — 
the  adenoid  and  the  fibrous — constitute  those  most  frequently 
met  with.  The  disease  is  a  rare  one,  but  numerous  cases  are 
recorded.  Why  the  wall  of  the  rectum  should  thus  become 
converted  into  a  surface  having  numerous  pendulous  projec- 
tions hanging  from  it,  it  is  not  possible  to  say ;  but  in  these 
extreme  cases  it  frequently  happens  that  not  only  is  the  rec- 
tum involved,  but  the  diseased  condition  extends  up  into  the 
large  bowel  above.  There  is  reason  to  suppose  that  the 
disease  is  in  some  sense  constitutional,  for  in  a  case  reported 


C06  THE   RECTUM 

by  Bickerstefh  ^  of  a  child  aged  11  years,  the  mother  had  also 
suffered  from  a  similar  condition ;  and  in  another  case, 
reported  by  T.  Smith,^  three  members  of  the  same  family  were 
all  exactly  similarly  affected. 

In  most  of  the  recorded  cases  it  would  appear  that  the 
disease  is  most  frequently  met  with  at  the  earlier  period  of 
life.  In  two  cases  recorded  by  Cripps,^  the  ages  were  respec- 
tively 19  and  17.  In  a  case  reported  by  Dunn,*  the  boy  was 
aged  10.  In  another  case,  by  Shattock,^  in  which  the  polypi 
were  composed  exclusively  of  lymphatic  tissue,  the  boy  was 
aged  4^.     In  Bickersteth's  case  the  child  was  11  years  old. 

Lymphomata. — It  occasionally,  though  rarely,  happens  that 
what  is  clinically  diagnosed  as  a  common  adenoid  or  fibrous 
polypus,  turns  out  on  microscopical  examination  to  be  com- 
posed entirely  of  lymphatic  tissue.  Ball  '^  describes  a  polypus 
which  with  another  formed  the  apex  of  a  prolapse  in  a  boy 
aged  6  years ;  on  microscopic  examination  both  tumours 
were  found  to  consist  solely  of  lymphatic  tissue.  Shattock's 
case  of  multiple  polypi  above  alluded  to  consisted  of  numerous 
sessile  growths,  all  exclasively  composed  of  the  same  lymphoid 
tissue.  In  these  cases  it  is  probable  that  the  polypi  have 
their  origin  in  the  solitary  glands  of  the  mucous  membrane. 

Myomata. — Tumours  developing  in  the  muscular  coat  of 
the  bowel,  and  composed  either  wholly  of  muscle,  or  of  this 
in  combination  with  fibrous  tissue,  are  sometimes  met  with. 
McCosh  '^  records  the  case  of  a  man  aged  34  years,  who  for 
some  years  had  had  increasing  difficulty  in  obtaining  evacua- 
tion of  the  bowels.  Latterly  the  only  faecal  matter  which  he 
had  been  able  to  pass  was  thin  and  ribbon-like.  On  examina- 
tion of  the  rectum  a  tumour  was  found  in  the  posterior  wall, 
extending  up  from  just  above  the  anus  to  the  hollow  of  the 
sacrum.  The  tumour  was  removed,  and  found  to  be  the  size 
and  very  much  the  shape  of  a  large  cocoanut.  It  was 
examined  and  declared  to  be  a  fibro-myoma,  springing  from 
the  muscular  coat  of  the  rectum.     Ball  *  also  refers  to  a  case 

'   St.  Barlholomeiu' s' Hospital  Eejjorts,  1890,  vol.  xxvi.  p.  299. 

2  Ihid.  1887,  vol.  xxiii.  p.  22-5.  »  Page  276. 

^  Trans.  Path.  Soc.  Land.  1890,  vol.  xli.  p.  139.  *  Ibid.  p.  137. 

°  Trans.  Royal  Academy  of  Medicine  in  Ireland,  1890,  vol.  viii.  p.  415. 

'  Annals  of  Surgery,  1893,  vol.  xviii.  p.  41. 

"  Trans.  Eoyal  Academy  of  Medicine  in  Ireland,  1890,  vol.  viii.  p.  415. 


SIMPLE   TUMOURS  607 

of  Macau's,  where  a  myoma  was  enucleated  from  the  wall  of 
the  rectum. 

Myxomata, — Tumours  of  this  character— as  indeed  most, 
if  not  all,  of  those  which  follow — are  of  the  nature  of  curiosi- 
ties rather  than  otherwise,  so  rarely  are  they  encountered  in 
practice.  A  tumour  of  this  particular  character  occurred  in 
a  woman  aged  63  years.  The  case  is  reported  by  Jones,'  who 
states  that  the  patient  had  complained  for  two  years  of 
symptoms  resembling  those  of  chronic  dysentery :  her  motions 
were  frequent,  but  nothing  except  a  little  blood  and  slime 
passed.  Examination  revealed  a  rounded  growth  lying  high 
up  between  the  rectum  and  the  vagina.  After  removal  it 
waa  found  to  consist  of  three  separate  tumours,  the  largest 
being  about  the  size  of  a  pullet's  egg  ;  the  other  two  were 
much  smaller.  The  microscope  showed  characters  of  a 
myxoma. 

Lipomata. — Fatty  tumours,  when  met  with,  arise  from  the 
submucous  tissue.  In  a  case  recorded  by  Voss,^  and  which 
by  some  is  quoted  in  illustration  of  a  fatty  tumour  in  this 
region,  the  growth  appears  to  have  had  its  origin  in  the 
sigmoid  flexure,  and  merely  descended  into  the  rectum.  The 
author,  however,  refers  to  two  other  cases,  one  by  Hoist  and 
another  by  Coupland. 

Cystomata. — In  illustration  of  cystic  tumours  the  following 
two  cases  may  be  instanced.  One  recorded  by  Prideaux,^  of 
a  woman  aged  28  years,  in  whom  parturition  was  complicated 
by  a  tumour  about  the  size  of  a  foetal  head,  attached  by  a 
long  pedicle  to  the  upper  part  of  the  rectum.  She  had  suffered 
for  years  from  obstinate  constipation.  After  removal  the 
tumour  was  found  to  contain  about  half  a  pint  of  thick  albu- 
minous fluid,  with  one  part  a  little  thicker  than  the  rest. 
Another  case  of  a  very  similar  character  occurred  in  the  prac- 
tice of  Adams  and  Parsons  Smith.''  After  a  normal  parturi- 
tion, the  patient,  a  woman  aged  30,  was  found  to  have  a 
*  thin,  pedunculated,  pyriform,  semi-transparent  cyst,'  about 
the  size  of  a  fcetal  head,  hanging  from  the  rectum.  The  cyst 
was  tapped,  and  eight  ounces  of  straw-coloured  fluid  drawn 
off ;  after  which  it  was  found  possible  to  return  it. 

'  Lancet,  1887,  vol.  ii.  p.  956.  -  London  Medical  Record,  1881,  p.  200. 

3  Lancet,  188B,  vol.  ii.  p.  G33.  ^  Ibid.  p.  881. 


608  THE   EECTUM 

Teratomata. — Dermoid  tumours  of  the  rectum  have  been 
met  with,  but  from  the  few  cases  recorded  they  must  be  of 
great  rarity.  Port  ^  reports  the  case  of  a  girl  aged  16  years, 
who  for  three  months  had  had  great  difficulty  and  forcing 
pain  in  passing  her  motions.  A  tumour  was  noticed  to  pro- 
ject partly  from  the  anus  with  a  mass  of  long  hair  attached 
to  it.  When  the  growth  was  removed,  it  was  found  to  be 
connected  by  two  pedicles  to  the  posterior  wall  of  the  gut, 
about  three  inches  from  the  anus.  It  was  composed  mostly 
of  fibrous  tissue  with  numerous  fat  cells,  and  contained  two 
masses  of  bony  substance  and  a  canine  tooth.  The  covering 
of  the  tumour  consisted  of  true  skin.  In  a  case  reported  by 
Danzel,^  a  woman  aged  25  years  complained  of  the  projection 
from  her  anus,  after  defecation,  of  long  hairs  which  interfered 
with  her  cle9,nliness,  and  necessitated  her  pulling  them  out. 
They,  however,  always  grew  again,  and  she  eventually  sought 
to  have  her  trouble  remedied.  On  examination  with  the 
finger,  guided  by  the  tuft  of  hair,  a  hard  tumour  about  the 
size  of  an  apple  was  felt  about  two  and  a  half  inches  up  from 
the  anus,  on  the  anterior  wall  of  the  gut.  It  was  removed, 
and  found  to  represent  a  true  dermoid,  containing  three 
spicules  of  bone,  some  fat,  a  tooth,  and  nerve  tissue,  with  a 
covering  of  true  skin. 

Angieomata  or  nsevus. — A  remarkable  example  of  this 
type  of  growth  has  been  recorded  by  E.  J.  Barker.^  The 
patient  was  a  man,  whose  first  symptom  was  an  attack  of 
diarrhoea,  accompanied  by  great  loss  of  blood.  He  usually 
suffered  from  constipation,  and  was  obliged  to  strain  much 
during  defecation.  Sometimes,  however,  he  had  intervals  of 
diarrhoea,  always  with  great  loss  of  blood.  He  felt  no  pain, 
did  not  lose  flesh,  and  had  no  particular  discharge  from  the 
rectum,  except  during  attacks  of  bleeding.  On  examining 
the  rectum  with  a  vaginal  speculum  and  with  artificial  light, 
a  mottling  was  observed  with  a  peculiar  purplish  tint.  Three 
shallow  ulcers  were  seen,  from  which  blood  freely  flowed. 
He  gradually  sank  from  loss  of  blood.  At  the  post  mortem 
the  wall  of  the  rectum  was  found  to  be  much  thickened  in 

'  Trans.  Path.  Soc.  Loncl.  1880,  vol.  xxxi.  p.  307. 
2  ArcJiivfiir  klin.  Cliir.  1874,  p.  442. 
^  Lancet,  1883,  vol.  i.  p.  637. 


INNOCENT  TUMOURS  609 

the  lower  four  inches  and  a  half  of  its  length  by  nsevoicl 
growth  in  its  walls,  on  the  rugse  of  which  three  ulcers  were 
seen  during  life. 

In  connection  with  this  case  Howard  Marsh  also  refers 
to  the  case  of  a  girl  aged  10  years,  who  for  eight  years  had 
suffered  from  repeated  and  sometimes  severe  haemorrhage 
from  the  bowels.  Antevoid  growth  was  detected  in  the  lower 
part  of  the  bowel  and  completely  surrounding  it.  The 
symptoms  were  relieved  by  several  applications  of  Paquelin's 
cautery,  but  the  disease  was  not  cured. 

Symptoms. — In  most  cases  the  symptoms  associated  with 
an  innocent  tumour  in  the  rectum  are  dependent  upon  the 
particular  configuration  of  the  growth  rather  than  upon  its 
histology ;  that  is  to  say,  a  tumour  hanging  by  a  pedicle,  in 
other  words  a  polypus,  will  produce  symptoms  much  the 
same  whether  it  be  composed  of  glandular  tissue,  fibrous 
tissue,  lymphatic  tissue,  or  any  one  of  the  other  connective 
tissues.  The  same  may  be  said  of  tumours  which  do  not 
become  pendulous,  but  which  project  into  the  canal  and 
cause  mechanical  obstruction. 

The  presence  of  a  polypus  in  the  rectum  is  usually  mani- 
fested by  frequent  discharges  of  mucus,  usually  of  thin  con- 
sistency and  often  fetid,  and  by  the  occasional  escape  of 
blood.  When  the  pedicle  of  the  polypus  is  long,  the  body  of 
the  tumour  is  sometimes  extruded  from  the  anus,  and  if  suffi- 
ciently tightly  constricted  it  becomes  congested,  or  may  get 
severed  from  its  attachment.  The  larger  the  size  of  the 
polypus  the  more  apt  it  is  to  create  a  feeling  of  discomfort 
within  the  bowel,  and  to  cause  the  sensation  of  imperfect 
evacuation  after  defecation.  A  remarkable  and  exceptional 
illustration  of  the  absence  of  symptoms  in  the  presence  of  a 
very  large  polypus  existed  in  Bowlby's  case  above  referred 
to.  Notwithstanding  the  enormous  size  of  the  tumour — 
'  as  large  as  a  foetal  head ' — the  patient  had  no  symptoms 
until  the  polypus  came  down  one  day  when  straining  at 
stool,  and,  its  reduction  not  being  possible,  it  had  to  be 
removed. 

As  a  rule,  however,  the  symptoms  are  dependent  upon  the 
size  of  the  tumour,  its  vascularity,  and  the  extent  of  the 
mucous  membrane  involved.     Thus  it  usually  happens  that 

E  R 


610  THE  RECTUM 

the  villous  growth,  which  is  very  vascular,  and  exposes  by  its 
ii-regular  papillomatous  surface  a  large  extent  of  secreting 
mucous  membrane,  causes  more  bleeding  and  more  mucous 
discharge  than  is  met  with  in  the  adenoid  or  fibrous  polypus. 
The  case  already  detailed  (Case  CIX.)  shows  how  large  a 
quantity  of  blood  may  be  lost  with  this  kind  of  tumour.  The 
amount  of  mucus  discharged  is  sometimes  seen  by  the  in- 
ability of  the  patient  to  prevent  a  constant  leakage  through 
the  anus  when  moving  about  in  the  erect  position. 

In  many  instances  tumours  growing  from  the  rectal  wall 
and  projecting  into  the  lumen  of  the  bowel  cause  obstruction  ; 
but  I  have  not  met  with  a  recorded  instance  where  the 
symptoms  have  advanced  to  the  stage  of  acute  intestinal 
obstruction.  Difficulty  in  defecation  was  a  prominent  sym- 
ptom in  Prideaux's  case  of  cystoma  and  in  Port's  case  of 
dermoid.  In  McCosh's  case  of  fibro-myoma,  besides  great 
difficulty  in  getting  a  movement  of  the  bowel,  the  faeces  when 
passed  were  always  thin  and  ribbon-like. 

Diagnosis. — When  the  tumour  projects  from  the  anus  it  is 
liable  to  be  mistaken  for  piles,  but  a  closer  examination  will 
reveal  its  true  nature.  There  is  also  a  danger  of  regarding 
the  occasional  heemorrhage  as  an  indication  of  the  same 
disease,  and  the  mistake  may  not  be  discovered  until  a  proper 
examination  is  made.  The  introduction  of  the  speculum  will 
in  many  cases  bring  a  tumour  into  view ;  but  palpation  by 
the  finger,  when  possible,  gives  the  fullest  information.  In 
using  the  finger  a  systematic  examination  of  the  rectum 
should  be  made,  otherwise  the  polypus  may  escape  detection. 
A  polypus  with  a  long  pedicle  may  have  its  body  carried 
upwards  out  of  reach,  and  this  even  may  be  done  at  the 
time  of  inserting  the  finger.  The  existence  of  a  cordlike 
structure  will  sometimes  indicate  that  the  body  of  the 
tumour  has  been  thus  displaced,  and  by  hooking  the 
finger  around  it  the  tumour  may  be  brought  within  touch. 
Better  information  is  therefore  obtained  when  withdrawing 
rather  than  when  inserting  the  finger.  Straining  on  the  part 
of  the  patient,  or  the  administration  of  an  enema,  will  often 
help  to  bring  down  a  growth  and  admit  of  its  being  seen  or 
felt. 

The  base  of  attachment  of  the  tumour  should  always  be 


INXOCEXT   TUMOUriS  611 

carefully  noted,  for  the  treatment  to  be  subsequently  adopted 
depends  upon  the  breadth  of  this  connection. 

Prog-nosis.— The  tendency  of  all  polypi  is  to  increase  in 
size,  and  for  the  pedicle  to  increase  in  length.  This  elonga- 
tion of  the  pedicle  sooner  or  later  admits  of  the  extrusion  of 
the  body  of  the  tumour  through  the  anus  during  the  act  of 
defecation,  and  as  a  result  the  veins  in  the  pedicle  become 
obstructed.  The  tumour  then  becomes  swollen  and  con- 
gested, and  if  much  enlarged  is  prevented  from  being 
reduced  within  the  bowel.  A  tumour  so  strangulated  is 
sometimes  severed  from  its  connection,  and  a  natural  cure 
results.  Allingham  believes  that  villous  tumours  at  times 
shed  themselves,  and  instances  a  case  in  point. 

No  truly  innocent  tumour  returns  after  complete  removal. 
The  doubtfully  innocent  nature  of  villous  growths  has  already 
been  alluded  to,  and  cases  cited  to  show  that  recurrence 
has  taken  place  after  removal,  and  that  the  new  growth  has 
manifested  the  characters  of  epithelioma. 

One  of  the  tendencies  of  a  polypus  is  to  produce  prolaj^se 
of  the  bowel ;  in  this  the  growth  exercises  a  similar  action 
to  what  occasionally  happens  in  both  the  large  and  small 
intestine.  The  constant  dragging  action  of  the  tumour  in 
these  latter  regions  causes  intussusception,  and  cases  have 
already  been  cited  of  a  polypus  in  the  rectum  being  found 
to  be  the  presenting  part  of  a  colic  intussusception.  (See 
p.  447.) 

Treatmeut. — Eemoval  is  the  only  method  of  successful 
treatment.  In  many  cases  of  simple  polypus  it  is  easy  to 
pull  down  the  tumour,  encircle  the  pedicle  with  a  ligature, 
and  snip  off  the  mass  with  a  pair  of  scissors.  If  the  pedicle 
be  long  and  narrow  it  may  be  twisted  off  with  a  pair  of 
forceps.  The  broader  the  pedicle  the  greater  the  care 
needed  in  securing  it,  as  vessels  of  considerable  size  some- 
times pass  from  the  mucous  membrane  into  the  body  of  the 
growth. 

When  from  the  position  of  the  tumour,  or  the  breadth  of 
its  basal  attachment,  it  cannot  be  dealt  with  simply,  the 
sphincter  should  be  dilated  and  the  base  of  the  growth 
transfixed  with  needle  and  suture.     A  broad  pedicle  should 

E    H    2 


612  THE  EECTUM 

be  ligatured  preferably  in  two  or  more  portions  rather  than 
encircled  by  a  single  thread. 

When  the  pedicle  has  been  tied,  the  tumour  may  either 
be  cut  away  or  left  to  slough  off.  If  there  is  any  risk  of 
much  bleeding,  it  is  safer  to  allow  the  mass  to  slough  away 
than  to  sever  its  connection  at  the  time  of  operating,  for  in 
the  latter  case  there  is  a  chance  of  the  ligature  slipping  off 
the  stump. 


CHAPTEE   LXXIV 
TUMOUES  {continued),     malignant  :    carcinoma  and  saecoma 

Or  the  two  large  classes  of  malignant  tumours,  the  carcinomata 
and  the  sarcomata,  the  former  affects  the  rectum  out  of  all 
proportion  to  the  latter ;  while  the  one  is  comparatively 
common,  the  other  is  only  met  with  in  rare  and  isolated 
instances. 

Carcinoma. — As  compared  with  carcinoma  in  other  parts 
of  the  intestine,  the  rectum  is  involved,  according  to  Ball,* 
in  about  80  per  cent,  of  the  entire  number  of  cases. 

The  disease  attacks  both  males  and  females,  but  with  a 
frequency  slightly  greater  in  the  case  of  the  former.  Stierlin  ^ 
gives  the  following  statistics  collected  by  him  :  Heuck,  in  a 
series  of  118  cases,  gives  a  ratio  of  1'8  male  to  1  female  ; 
Stierlin  with  41  cases,  Bryant  with  60,  and  Hildebrand  with 
187,  give  a  ratio  of  2  males  to  1  female.  As  contrasting 
somewhat  with  this  greater  proportion  of  males  to  females, 
Williams,  out  of  a  series  of  257  cases,  found  that  130  were 
males  and  127  females ;  while  Kelsey,  out  of  107  cases,  had 
60  males  and  57  females.  In  the  experience  of  Allingham 
and  most  other  surgeons,  however,  the  preponderance  of  the 
disease  in  males  is  the  rule. 

As  regards  age,  the  disease  is  essentially  one  of  adult  life, 
and  is  met  with  at  any  period  after  twenty  years.  Cases, 
however,  are  not  wanting  to  illustrate  its  appearance  in 
patients  under  this  age.  Thus  the  following  are  quoted  in 
most  of  the  textbooks:  Mayo,  a  boy  aged  12;  Gowlland,  a 

■  Tj-ans.  of  the  Royal  Academy  of  Medicine  in  Ireland,  1893,  vol.  xi.  p.  166. 
2  Beitrage  zur  Uin.  Cliir.  1889,  Bd.  v.  p.  646. 


CARCINOMA— PATHOLOGY  613 

boy  aged  13  ;  Godwin,  one  aged  15  ;  Quain,  one  aged  16  ; 
Cripps  and  Allingham,  each  a  boy  aged  17 ;  and  Schoening 
two  girls,  each  also  aged  17. 

Pathology  of  rectal  carcinoma, — It  was  pointed  out  before 
discussing  the  pathology  of  carcinoma  of  the  large  bowel  that, 
prior  to  speaking  of  the  various  kmds  of  carcinoma  which 
may  involve  the  gut,  some  definite  understanding  must  be 
had  of  the  significance  of  the  terms  used.  The  same  reason- 
ing equally  applies  here,  and  the  reader  is  asked  to  refer  to 
p.  465  for  a  description  which  need  not  be  repeated. 

Adopting  therefore  the  threefold  classification  of  carci- 
noma— the  squamous-celled,  spheroidal-celled,  and  columnar- 
celled — the  rectum  appears  to  be  aflected  almost  exclusively 
by  the  last.  In  almost  every  instance  where  the  record  of  a 
case  carries  with  it  the  microscopical  description  of  the  growth, 
the  disease  is  described  as  of  this  character.  And  where 
such  terms  as  '  schirrous,'  'medullary,'  or  *  encephaloid'  are 
used  they  invariably  have  a  clinical,  and  not  a  strictly  histo- 
logical, significance  ;  that  is  to  say,  the  terms  are  intended 
to  imply  either  that  the  tumour  tissue  is  indurated  and 
possibly  of  slow  growth,  or  that  it  is  soft,  pulpy,  and  probably 
rai^idly  growing. 

Carcinoma  of  the  rectum,  as  just  indicated,  presents  many 
differences  in  its  character.  Both  as  regards  its  origin  and 
its  development  marked  variations  are  met  with.  Why  a 
tumour  presenting  in  its  intimate  structure  such  constant 
uniformity  should,  in  process  of  development,  exhibit  such 
striking  differences  it  is  impossible  to  say.  But  the  reason, 
whether  a  constitutional  or  a  local  one,  is  probably  the  same 
as  that  which  effects  similar  modifications  in  the  growth  of 
carcinoma  m  other  parts  of  the  body ;  and  until  more  is 
known  generally  about  the  etiology  of  carcinoma,  it  is  impos- 
sible to  attempt  to  explain  the  numerous  and  variable  phases 
which  it  presents  in  its  process  of  development. 

In  the  origin  and  progress  of  carcinomatous  disease  two 
special  forms  are  described  by  Cripps  :  ^  the  one  known  as 
the  '  laminar  '  is  characterised  by  its  tendency  to  spread 
as  a  thin  layer  between  the  mucous  and  muscular  coats  of 
the  bowel ;  this  form  finally  gives  rise  to  the  well-recognised 

'  P.  32]. 


6U  THE   RECTUM 

annular  stricture.  The  other  form  tends  to  increase  uniformly 
in  all  directions  both  superficially  and  deeply,  and  by  so  doing, 
to  produce  a  tumour  which  projects  into  the  bowel ;  the 
mucous  membrane  at  an  early  stage  covers  the  tumour,  but 
sooner  or  later  it  gives  way,  and  an  ulcerating  mass  projects 
which  may  be  as  soft  as  brain  tissue. 

Of  these  two  types  of  disease  the  laminar — or,  as  it  is 
better  known  in  its  more  advanced  stage,  the  annular  stric- 
ture— is  the  more  common.  According  to  Stierlin,  70  per  cent, 
of  the  cases  recorded  by  him  were  of  this  nature,  Lovinsohn's 
series  contained  74  per  cent.,  and  Heuck  gives  76*7  per  cent. 
In  Stierlin's  remaining  cases  the  disease  was  distributed 
about  equally  on  the  anterior  and  posterior  walls  of  the 
bowel. 

Carcinoma  is  met  with  in  any  part  of  the  rectum,  but 
appears  to  be  more  frequently  seated  within  the  first  two  or 
three  inches  from  the  anus.  In  Stierlin's  41  cases  the 
disease  was  in  28  situated  mostly  from  3  to  4  ctms.  above 
the  anus ;  in  12  it  was  seated  higher  up. 

The  appearance  under  the  microscope  of  a  section  of  rectal 
carcinoma  is  usually  very  typical.  In  general  structure  it 
presents  the  character  of  a  gland,  and  so  constantly  is  this 
character  present  that  it  has  received  the  name  of  'malignant 
adenoma,'  or  '  adenoid  carcinoma.'  A  section  shows  numerous 
elongated  or  round  tubular  structures  irregularly  disposed 
and  of  somewhat  unequal  calibre.  In  most  sections  a  uniform 
layer  of  columnar-shaped  cells  is  seen  lining  the  tubular  or 
alveolar  spaces  ;  it  is  frequent,  however,  to  see  gaps  in  the 
lining,  due  to  the  dislodgment  of  cells  in  the  process  of 
mounting.  The  tubuli  and  alveoli  are  filled  with  cells, 
but  these  also  are  liable  to  be  washed  away  and  leave  clear 
and  empty  spaces.  The  relative  proportion  of  cells  and  inter- 
cellular tissue  varies,  as  does  also  the  stage  of  development 
or  degeneration  which  each  may  reach.  These  variations 
depend  largely  upon  the  rapidity  of  growth.  Thus  in  a 
rapidly  growing  tumour  the  cells  are  proportionately  more 
abundant  and  less  typical  in  character  ;  while  the  intercellular 
tissue  is  less  perfectly  developed,  and  often  appears  as  spindle- 
shaped  cells  rather  than  as  fibrous  tissue.  Tumours  of  this- 
character  form  what  are  known  clinically  as  medullary  or 


PLATE    XXVll 


Fig.  104.— Colloid  Carcinoma  of  Rectum.— The  illustration  shows  a  longitudinal 
section  of  the  rectum  with  the  bladder  in  front.  The  wall  of  the  rectum  is 
thickened  and  infiltrated.     (W.I.M.,  Glas.) 


CARCINOMA- PATHOLOGY  615 

cnceplialoid  growths.  In  a  more  slowly  growing  tumour  the 
tw^o  primary  constituents  reach  a  stage  of  more  perfect 
development,  and  the  intercellular  fully  formed  fibrous  tissue 
may  predominate  over  the  well-defined  columnar-shaped  cells. 
In  the  so-called  scirrhous  form  of  the  disease,  this  is  the  type 
most  usually  met  with. 

Colloid  carcinoma. — What  relation  this  bears,  if  any,  to 
the  form  of  carcinoma  just  described  is  not  definitely  known. 
If  it  may  be  looked  upon  as  the  result  of  a  degenerative 
change  in  the  columnar  cells  of  the  common  adenoid  form  of 
the  disease,  its  pathological  connection  with  it  becomes  at 
once  simplified.  Pathologists,  however,  are  not  at  one  on 
such  an  explanation,  and  the  disease  must  therefore  for  the 
present  be  considered  separately. 

Colloid  carcinoma  of  the  rectum  is  but  rarely  met  with, 
although  undoubted  examples  of  its  occurrence  are  recorded. 
Allingham  ^  mentions  having  seen  many  colloid  tumours  ;  but 
his  own  words  which  follow  seem  rather  to  oppose  the  view 
that  they  were  all  of  the  nature  of  true  colloid  as  here  described, 
for  he  adds,  '  I  am  not  sure  that  encephaloid  may  not  be 
colloid  or  pass  into  it.'  Ball  ^  relates  having  seen  two 
examples,  one  of  which  is  figured  and  presents  a  very  typical 
illustration  of  the  disease.  Arnot  ^  records  an  interesting 
example  of  the  disease  in  a  woman  aged  27.  The  growth 
almost  entirely  obliterated  the  canal  and  extended  to  the 
anus.  It  there  protruded  and  involved  the  perineum  in  one 
large  mass  of  firm,  semi-translucent  material.  The  growth 
also  involved  the  lymphatic  glands  in  front  of  the  spine  and 
pressed  upon  the  vena  cava.  In  the  pelvis  it  bound  together 
the  viscera  into  a  solid  mass. 

In  structure,  colloid  carcinoma  follows  the  type  of  the 
growth  as  met  with  in  other  parts  of  the  body.  The  stroma, 
in  place  of  containing  typical  epithelial  cells,  is  filled  with  a 
translucent  jellylike  material  which  distends  the  loculi  into 
spaces  of  variable  size  and  shape. 

Melanotic  carcinoma. — While  many  cases  are  on  record  of 
melanotic  cancer  of  the  bowel,  it  is  not  easy  to  determine 

'  p.  271. 

-  Trans,  of  the  Royal  Academy  of  Medicine  in  Ireland,  1893,  vol.  xi.  p.  168. 
^  Trans.  Path.  Soc.  Lond.  1875,  vol.  xxvi.  p.  122. 


616  THE   RECTUM 

whether  in  all  cases  this  expression  indicates  a  pigmented 
carcinoma  or  a  pigmented  sarcoma.  The  fact,  however,  that 
in  nearly  every  instance  where  the  growth  was  carefully 
examined  microscopically  it  was  fomid  to  be  sarcoma  renders 
it  probable  that  a  pigmented  carcinoma  is  either  never  met 
with  or  is  extremely  rare. 

Osteoid  carcinoma. — As  this  disease,  like  that  just  described, 
is  usually  indefinitely  spoken  of  as  a  cancer,  it  is  possible 
that  it  too  should  be  considered  as  of  the  nature  of  a  sarcoma. 
The  disease,  however,  is  of  exceptional  rarity,  and  the  only 
recorded  case  is  that  of  Wagstaffe,*  which  is  found  referre 
to  in  almost  every  work  on  diseases  of  the  rectum. 

Progress  of  the  disease. — The  course  which  carcinoma 
pursues  resembles  that  followed  by  it  when  occurring  in  other 
parts  of  the  alimentary  tract,  modified  only  by  the  special 
anatomical  relations  of  the  region  affected.  Its  progress  may 
be  considered  from  two  aspects,  the  local  and  the  remote. 

Locally  the  disease  as  it  develops  affects  in  the  first  place 
the  bowel  itself,  and  then,  by  direct  extension,  the  parts  in  the 
immediate  neighbourhood. 

The  manner  in  which  the  bowel  is  affected  depends  prin- 
cipally upon  the  nature  of  the  growth.  It  may  block  the 
canal  either  by  projecting  into  it  as  a  mass  of  tumour  tissue,  or 
by  constricting  it  with  a  hard  and  resistant  fibrous-like  band. 
When  the  obstruction  is  brought  about  by  projecting  masses 
these  sooner  or  later  break  down,  and  leave  large  ulcers,  and 
fungating  masses  of  tissue  which  frequently  bleed  freely. 
When  the  growth  extends  backwards  into  the  hollow  of  the 
sacrum,  it  may  press  upon  or  invade  the  sacral  plexus,  and 
by  so  doing  be  the  cause  of  pain  felt  in  the  peripheral  distri- 
bution of  the  nerves  derived  from  it.  Thus  that  kind  of  pain 
so  often  described  by  the  patient  as  like  rheumatism  or  sciatica 
may  owe  its  existence  to  some  such  implication.  In  the  case 
of  stricture,  other  changes  are  brought  about  by  the  con- 
stant and  increasing  obstruction  to  the  passage  downwards 
of  the  contents  of  the  bowel  above  the  stricture.  These 
resemble  those  already  described  in  the  case  of  non-malignant 
stricture,  and  consist  of  dilatation  of  the  bowel  above  the 
obstruction,  with  inflammation  and  ulceration  the  result  of* 

'   Trmis.  Path.  Soc.  Lond.  1869,  vol.  xx.  p.  176. 


CARCINOMA  617 

constant  fa;cal  irritation.  Ulceration  may  take  place  at  any 
part  of  the  large  intestine,  and  not  necessarily  immediately 
above  the  stricture.  If  ulceration  progresses  it  may  lead  to 
rupture  or  perforation.  In  a  case  reported  by  Way/  a  rent 
admitting  the  passage  of  three  fingers  \Yas  found  in  the 
CiTBCum,  and  much  fnecal  matter  had  escaped  into  the  perito- 
neal cavity.  The  accident  was  ushered  in  with  sudden  intense 
abdominal  pain,  following  upon  several  months  of  persistent 
symptoms  of  intestinal  obstruction.  In  another  case,  recorded 
by  Poulton,"-^  two  perforations  of  the  ascending  colon  took  jolace 
just  above  the  caecum.  Death  occurred  from  acute  peritonitis, 
and  fseces  were  found  in  the  peritoneal  cavity. 

Ulceration  may  also  lead  to  the  contraction  of  adhesions 
between  the  rectum  and  neighbouring  viscera,  and  in  this  way 
localised  abscesses  sometimes  form  which,  bursting  into  the 
bladder,  urethra,  vagina,  or  uterus,  establish  fistulous  com- 
munications. Such  results  as  recto-vesical  fistulge  are  not 
uncommon,  and  cause  much  suffering  in  micturition.  In  one 
of  my  cases  this  complication  proved  the  sole  source  of  the 
patient's  suffering,  and  for  it  I  had  to  make  a  sigmoid  anus. 
When  ulceration  extends  into  the  ischio-rectal  fossae,  acute 
inflammation  and  suppuration  follow,  with  the  result  that  one 
of  the  worst  forms  of  fistula  in  ano  is  caused.  In  one  such 
case  upon  which  I  operated,  the  patient  was  admitted  into  the 
hospital  with  extensive  acute  inflammation  commencing  in 
the  region  of  the  anus  and  extending  for  some  distance  over 
both  buttocks.  When  freely  incised,  a  quantity  of  gas  and 
excessively  putrid-smelling  faeces  escaped,  and  a  large  cavity 
was  left  with  shreddy  sloughs  adherent  to  its  walls,  and  laying 
bare  the  coccyx. 

In  rare  instances  the  abscess,  instead  of  bursting  externally, 
reopens  into  the  bowel  below  the  stricture,  and  thus,  as 
happens  in  the  urethra,  a  new  channel  is  opened  up  for  the 
discharge  of  the  hitherto  obstructed  faeces. 

In  cases  of  ring  stricture  it  occasionally  happens  that  the 
narrowed  orifice  becomes  suddenly  blocked,  and  symptoms  of 
obstruction  set  in  which  are  not  necessarily  acute  in  character, 
but  tend  to  be   so  the  higher   the  seat  of  the   obstruction. 

'   Trans.  Path.  Soc.  Lond.  1875,  vol.  xxvi.  p.  104. 
^  Australasian  Medical  Gazette,  1894,  vol.  xiii.  p.  84. 


618  THE  RECTUM 

Another  cause  of  intestinal  obstruction  is  the  formation  of  a 
rectal  intussusception.  The  constant  efforts  on  the  part  of 
the  bowel  above  to  drive  on  its  contents  causes  the  strictured 
ring  to  descend ;  and,  although  usually  more  or  less  gradual 
in  its  process,  it  may  suddenly  amount  to  a  complete  intussus- 
ception, with  the  result  of  creating  an  impervious  canal. 

The  bowel  below  the  seat  of  obstruction  also  suffers  from 
changes  similar  to  those  described  in  connection  with  simple 
cicatricial  stricture.  When  the  disease  is  situated  high  up  in 
the  rectum,  the  portion  below  often  becomes  '  ballooned,'  the 
cavity  of  the  bowel  being  markedly  expanded,  and  for  the 
same  reason  as  already  explained  in  discussing  the  conditions 
in  simple  stricture  (see  p.  596).  Internal  haemorrhoids  are 
frequently  present ;  and  when  the  disease  is  situated  low 
down,  the  anus  may  be  invaded  or  may  be  patulous  and 
cedematous,  and  possibly  excoriated  by  the  constant  escape  of 
putrid  and  irritating  discharges. 

In  considering  the  remote  changes  effected  by  the  progress 
of  the  disease,  the  anatomy  of  the  part  must  be  borne  in  mind. 
The  fact  that  carcinoma  may  be  carried  into  distant  parts, 
both  by  the  lymphatics  and  by  the  veins,  renders  it  important 
to  consider  the  course  which  these  vessels  take  in  their  passage 
from  the  initial  seat  of  the  disease.  By  reference  to  the  anatomy 
of  the  rectum  it  will  be  found  that  the  lymphatics  from  all 
parts  of  the  rectum  above  the  anus  proceed  to  the  sacral 
glands  in  the  hollow  of  the  sacrum  and  to  the  lumbar  glands 
along  the  sides  of  the  lumbar  vertebrae  ;  while  the  veins  return 
their  blood  into  the  portal  vein  and  into  the  inferior  vena 
cava.  Hence,  in  seeking  to  ascertain  if  the  lymphatic  glands 
are  enlarged,  the  sacral  glands  must  be  examined  through  the 
posterior  wall  of  the  rectum  and  the  lumbar  glands  by  pres- 
sure exercised  through  the  anterior  abdominal  wall.  These 
glands  sometimes  enlarge  to  the  size  of  a  hen's  egg  or  even 
larger,  and  can  then  be  easily  felt. 

In  distribution  of  the  disease  by  the  veins,  the  liver  is  the 
first  to  become  involved,  and  in  some  instances  so  markedly 
does  this  involvement  take  place  that  its  large  size  and 
nodular  and  irregular  outline  constitute  a  prominent  feature 
in  the  case.  Systemic  infection  through  the  vena  cava  is 
shown  by  involvement  of  the  lung  and  other  parts  of  the  body. 


CARCINOMA— SYMPTOMS  619 

A  case  of  secondary  infection  of  the  lung  was  shown  at  a 
Branch  meeting  of  the  British  Medical  Association  hy  F. 
Marsh.'  Pitts  "^  records  the  case  of  a  spontaneous  fracture  of 
the  humerus.  Amputation  of  the  arm  was  performed.  "When 
the  tumour  was  examined  microscopically,  it  was  found  to  he 
so  perfect  in  resemhlance  to  the  tumour  in  the  rectum  that 
it  was  impossible  to  distinguish  the  one  from  the  other. 
Marcus  ^  is  quoted  as  having  reported  a  case  of  secondary 
infection  of  the  brain. 

Another  effect  of  the  absorption  into  the  blood  of  substances 
connected  with  the  growth  is  the  production  of  a  peculiar 
sallow  complexion,  the  so-called  cachexia.  This  is  usually 
considered  a  feature  of  some  diagnostic  value  in  all  cases  of 
advanced  carcinoma,  but  more  particularly  is  it  so  in  rectal 
disease. 


CHAPTEE  LXXV 


CAKCiNOMA  (continued),     symptoms,     diagnosis,     pkognosis 

EBGARDING    OPERATIONS 

Symptoms. — Like  most  diseases  involving  the  alimentary 
tract,  the  early  symptoms  are  often  of  an  extremely  vague  and 
uncertain  character.  It  is  as  a  rule  not  until  a  comparatively 
advanced  period  that  symptoms  in  any  degree  typical  of  the 
disease  are  present. 

As  will  be  gathered  from  what  has  been  said  in  connection 
with  the  pathology  of  the  disease,  there  can  be  no  uniformity 
or  constancy  in  the  symptoms  manifested.  The  nature 
of  the  growth,  its  seat  and  extent,  affect  as  much  as  any- 
thing, the  symptoms  present;  and  if  to  these  be  added 
the  natural  differences  of  susceptibility  which  patients  ex- 
hibit regarding  discomforts  and  pain,  it  will  at  once  be  seen 

'  Brit.  Med.  Journ.  1891,  vol.  i.  p.  857.  (In  reply  to  a  letter  sent  in  the 
autumn  of  1895,  Dr.  Marsh  informed  the  author  that  the  patient  whom  he  had 
exhibited  as  apparently  suffering  from  lung  infection  had  died  with  symptoms 
of  increased  involvement  of  the  lungs,  but  that  a  post  mortem  had  not  been 
obtainable.) 

-  Trans.  Path.  Soc.  Lond.  1891,  vol.  xlii.  p.  267. 

=*  Index  Medicios,  1890,  p.  67. 


620  THE   RECTUM 

how  extremely  variable  must  be  the  symptoms  present  in  each 
case. 

Constipation  and  diarrhoea. — Among  the  earliest  indications 
of  the  disease,  and  more  particularly  of  that  form  of  it  which 
results  in  the  annular  or  ring  stricture,  is  gradually  increasing 
difficulty  in  defecation.  The  onset  and  progress  of  the  diffi- 
culty are  naturally  very  insidious,  and  it  is  only  when  the 
patient  begins  to  find  it  needful  to  render  the  motions  lax  by 
aperients,  in  order  to  get  a  passage,  that  a  suspicion  is  enter- 
tained regarding  the  possible  nature  of  the  complaint.  It  is 
often  also  at  this  early  stage  that  some  little  bleeding  is  fre- 
quently noticed  ;  and  the  patient  is  misled  into  the  belief 
that  the  haemorrhage  is  the  result  of  piles.  When  obstruction 
has  reached  a  certain  stage,  a  spurious  diarrhoea  often  sets  in 
and  the  patient  is  compelled  to  make  frequent  efforts  to  empty 
the  bowel,  although  little  more  than  some  blood-stained  muco- 
purulent material  may  be  discharged. 

The  fceces  in  their  character  frequently  constitute  an 
important  diagnostic  feature  in  the  disease.  When  the 
obstruction  is  situated  low  down  in  the  rectum,  the  motions 
may  be  modified  in  shape.  They  may  be  flattened,  narrowed 
like  pipe-stems,  or  grooved.  If  the  obstruction  is  higher, 
they  may  be  entirely  wanting  in  form.  In  most  cases  where 
the  disease  is  at  all  advanced,  the  motions  are  loose,  and 
coated  or  streaked  or  mixed  with  blood-stained  mucus  or 
possibly  with  pus.  The  amount  of  blood  lost  varies,  but  is  as 
a  rule  small  in  quantity.  The  excessively  offensive  smell  of 
the  discharges  observed  in  some  cases  constitutes  almost  a 
pathognomonic  sign  of  carcinoma. 

The  2Min  felt  is  extremely  variable,  both  in  kind  and  in 
intensity.  In  some  cases  it  is  so  slight  that  not  until  within 
a  short  time  before  death  is  any  complaint  made.  Unfor- 
tunately this  complete  absence  of  pain  is  the  exception  rather 
than  the  rule.  Pain  of  some  kind  is  generally  felt  throughout 
the  disease,  and  in  many  instances  it  becomes  of  such  a  severe 
and  constant  character,  that  there  are  few  troubles  which 
cause  more  acute  suffering.  The  simplest  type  of  pain  is  that 
which  consists  in  little  more  than  a  constant  feeling  of  dis- 
comfort at  not  being  able  to  successfully  empty  the  bowel. 
The  existence  of  ulceration  and  involvement  of  nerves  probably 


CARCINOMA— DIAGNOSIS  621 

accounts  for  the  severer  types  of  pain.  The  patient  complains 
of  a  feeling  of '  burning,'  which  is  often  worse  after  a  move- 
ment of  the  bowels  ;  or  there  is  a  constant  sensation  of  weight 
in  the  part,  with  possibly  a  dull  gnawing  pain  at  the  back  of 
the  sacrum.  When  the  pain  is  reflected  down  the  legs,  it  is 
sometimes  described  as  '  sciatica.'  Occasionally  pain  is  com- 
plained of  in  the  abdomen. 

Other  symptoms  become  manifest  as  the  disease  progresses 
and  produces  its  various  complications.  The  complexion  of 
the  patient  is  frequently  markedly  sallow ;  loss  of  sleep  and 
loss  of  appetite  co  exist  with  loss  of  flesh  and  loss  of  strength. 
There  may  be  enlargement  of  the  liver,  with  possibly  some 
irregularity  of  its  edge  and  surface.  Deep  palpation  of 
the  abdomen,  either  with  or  without  an  anaesthetic,  may  also 
reveal  the  presence  of  enlarged  lymphatic  glands.  The  in- 
creasing obstruction  may  cause  distension  of  the  abdomen, 
and  griping  pains  will  indicate  the  fruitless  efforts  of  the 
peristaltic  wave  to  overcome  the  obstruction.  If  complete 
blockage  of  the  narrowed  channel  should  take  place,  symptoms 
of  intestinal  obstruction  follow.  As  a  rule  these  are  not  of 
the  same  acute  character  as  when  the  bowel  is  obstructed  in 
the  colon  or  small  intestine ;  and  may  be  said  to  be  less  severe 
the  lower  the  disease  is  situated  in  the  rectum.  It  is  not  un- 
common for  vomiting  to  continue  for  several  days  before  it 
becomes  fsecal,  and  for  the  patient  during  this  time  not  to  be 
particularly  distressed  or  put  about. 

The  sudden  onset  of  acute  abdominal  pain,  in  a  patient 
not  otherwise  very  ill,  must  be  considered  as  probably 
indicating  rupture  or  perforation  of  the  bowel  above  the 
obstruction. 

Diagnosis. — No  diagnosis  of  carcinoma  of  the  rectum  can 
be  said  to  be  rendered  perfectly  certain  unless  the  disease 
can  be  either  seen  or  felt.  Hence  it  follows  that  it  is  only 
when  it  is  seated  within  the  lower  six  inches  of  the  gut  that 
a  definite  opinion  can  be  expressed.  The  reason  of  this 
arises  from  the  fact  that,  when  a  carcinomatous  stricture 
involves  the  upper  part  of  the  rectum,  its  diiferential  diagnosis 
from  obstruction  due  to  simple  stricture  is  very  difficult,  and 
at  the  most  can  only  be  conjectured  from  such  facts  as  the 
age  of  the  patient,  the  length  of  time  the  symptoms  have 


622  THE   RECTUM 

existed,  and  the  general  appearances  and  conditions  repre- 
sented. 

"When  the  finger  can  reach  the  seat  of  the  disease,  what 
is  felt  will  depend  upon  the  nature  and  extent  of  the  growth. 
In  any  case  of  donbt  it  is  possible  to  remove,  either  with  the 
finger  nail  or  with  .a  pair  of  forceps,  a  small  piece  of  the 
tumour  tissue  for  microscopic  examination.  When  the  finger 
cannot  reach  the  disease,  it  may  be  possible  to  see  it  with  a 
speculum,  and  to  verify  the  diagnosis  by  the  removal  of  a 
fragment  for  examination. 

Cripps  ^  attaches  some  weight,  in  distinguishing  between 
an  innocent  and  a  malignant  stricture,  to  the  condition  of  the 
mucous  membrane  between  the  anus  and  the  strictured  part. 
In  the  former  the  mucous  membrane  is  somewhat  hard  and 
contracted,  portions  of  it  instead  of  feeling  soft  and  supple 
are  often  hard  and  creaking,  as  if  replaced  by  cicatricial  tissue  ; 
while  in  the  latter  the  mucous  membrane  is  generally  com- 
paratively healthy. 

Assistance  in  the  diagnosis  of  a  stricture  in  the  upper 
part  of  the  rectum  may  be  obtained  by  the  method  of 
injection,  by  the  use  of  bougies,  and  by  the  presence  of 
'  ballooning  '  of  the  bowel  below.  Eeference  should  be  made 
to  these  diagnostic  measures  when  discussed  in  connection 
with  non-malignant  stricture.  It  should,  however,  be  briefly 
repeated  here  that  bougies,  if  employed  at  all,  must  be  used 
with  the  utmost  care ;  for  if  there  is  danger  of  perforating 
the  bowel  in  simple  stricture,  much  more  is  this  the  case 
in  malignant  disease. 

Prognosis. — The  inevitably  fatal  nature  of  the  disease 
renders  the  question  of  prognosis  one  dependent  upon  the 
relative  merits  of  the  different  modes  of  treatment.  The 
question  becomes  one  simply  of  determining  how  much  longer 
a  patient  can  live  after  treatment  than  if  no  treatment  had 
been  adopted. 

As  regards  length  of  life  independently  of  treatment  of  any 
kind — that  is  to  say,  the  length  of  time  the  disease  takes  to 
run  its  natural  course — great  differences  necessarily  exist. 
For  not  only  are  there  innumerable  variations  in  the  modes 
of  involvement  of  the  bowel,  and  in  the  rapidity  with  which  the 

'  P.  369. 


CARCrNOMA— PROGNOSIS  G23 

f^rowth  progresses  and  implicates  other  parts,  but  the  greatest 
possible  difficulty  exists  in  fixing  the  period  at  which  the 
disease  commenced.  Cases  are  recorded  where  the  first 
symptoms  experienced  by  the  patient  were  those  of  acute 
intestinal  obstruction — in  other  words,  the  patient  had  lived 
in  apparent  health,  with  little  or  no  indication  of  the  disease 
which  was  slowly  progressing  and  shortly  to  terminate  in 
death.  As  a  rule  the  younger  the  patient  the  more  rapid 
is  the  progress  of  the  disease  ;  hence  in  old  people  we  find 
that  life  is  often  much  prolonged.  It  may  be  approximately 
said  that  the  patient  lives  for  about  a  couple  of  years 
after  the  first  appearance  of  the  disease  as  manifested  by 
symptoms.  Death  then  results  from  exhaustion.  Should 
complications  arise  they  may  hasten  the  end,  and  if  these  are 
of  the  nature  of  complete  obstruction  or  perforation  a  more 
or  less  rapidly  fatal  result  ensues.  There  is,  in  many 
instances,  little  or  nothing  to  guide  in  reckoning  the  possible 
length  of  life  in  any  particular  case,  except  it  be  the  special 
nature  of  the  tumour  which  it  is  possible  either  to  see  or 
feel. 

Prognosis  in  regard  to  treatment  concerns,  in  the  first 
place,  simply  the  relief  of  the  patient's  symptoms,  and,  in  the 
second,  the  possibility  of  curing  the  disease. 

No  subject  in  surgery  has  afforded  a  field  for  keener 
conflict  than  that  which  concerns  the  operative  treatment 
of  this  disease.  The  contending  parties  are  those  who 
advocate  the  formation  of  an  artificial  anus  either  in  the 
groin  or  in  the  loin,  and  those  who  advise  radical  treat- 
ment by  extirpation.  The  aims  are  totally  distinct,  and  as 
the  means  to  procure  the  ends  differ  so  greatly  in  their  nature 
and  severity,  it  must  be  clearly  shown  that  the  severer 
measure  of  extirpation  justifies  the  rejection  in  certain  cases 
of  the  comparatively  safe  and  purely  palliative  operation  of 
making  an  artificial  anus. 

In  discussing  the  merits  of  extirpation,  the  two  primary 
methods  of  operating  must  be  considered  separately.  These 
methods  are  the  removal  of  the  disease  when  situated  in  the 
lower  half  of  the  rectum,  by  operating  through  the  perineum  ; 
and  removal  of  the  disease  when  seated  in  the  upper  half,  by 
operating  through  the  sacral  region.     The  greater  magnitude 


624  THE   RECTUM 

of  the  latter  operation  necessarily  causes  it  to  rank  as  the 
severer  method  of  the  two. 

In  weighing  the  merits  of  either  of  these  operations,  it 
must  be  understood  that  in  both,  suitable  cases  are  selected 
for  the  treatment.  Incomplete  removal  of  the  primary  seat  of 
the  disease  in  carcinoma,  occurring  in  any  part  of  the  body, 
is  invariably  followed  by  conditions  worse  than  those  for 
which  the  operation  was  originally  performed.  This  specially 
applies  to  disease  in  the  rectum,  where  the  part  of  the  tumour 
left  behind  takes  on  a  renewed  activity  in  growth,  and  re- 
contraction  rapidly  follows  with  a  return,  in  possibly  an 
augmented  condition,  of  the  original  symptoms.  I  cannot  do 
better  than  illustrate  by  a  case  the  pitiable  results  that 
imperfect  removal  may  entail ;  for  if  such  results  are  possible 
it  behoves  the  surgeon  to  doubly  consider  the  advisability  of 
attempting  the  extirpation  when  there  is  not  good  reason  for 
assuming  the  possibility  of  removing  the  primary  seat  of  the 
disease. 

Case  CX. — Illustrating  the  had  effects  of  jjerineal  excision  of  the 

rectum. 

A  woman  aged  43  was  admitted  complaining  of  loss  of  blood,  from 
time  to  time,  from  the  rectum,  five  inches  of  which  had  been  removed 
eighteen  months  previously  for  local  causes.  She  had,  however,  received 
but  little  benefit  from  the  operation.  Liquid  faeces  were  constantly  flow- 
ing away.  There  was  great  excoriation  of  the  left  buttock,  and  ulceration. 
The  orifice  of  the  rectum  was  nearly  closed  by  a  tight  cicatricial  stricture, 
through  which  the  tip  of  the  finger  could  just  pass.  There  was  bleeding 
after  admission  into  hospital,  as  much  as  a  pint  being  lost  on  two  or  three 
occasions.  Digital  examination  of  the  rectum  detected,  about  three  or 
four  inches  up,  a  hard  mass  at  the  posterior  wail  of  the  gut.  (Thomas 
Bryant,  '  Clin.  Journ.'  1893,  vol.  ii.  p.  213.) 

It  might  justly  be  argued  in  this  case  that  the  bad  after 
effects  were  more  due  to  the  inefficient  treatment  carried  out 
after  the  operation  than  to  the  operation  itself ;  for  had 
dilatation  been  constantly  and  carefully  maintained,  the 
troubles  connected  with  the  stricture  might  never  have  been. 
But  that  such  after  care  is  needed,  is  a  serious  objection  to 
the  operation,  because  of  the  known  difficulty  which  exists  in 
getting  patients  to  persist  in  carrying  it  out.  I  remember 
making  the  post  mortem  upon  a  man  whose  rectum  had  been 


CARCINOMA— PROGNOSIS  6i>o 

excised  some  months  previously  ;  his  hfe  latterly  became  one 
of  such  abject  misery  that  he  committed  suicide. 

I  will  consider  first,  prognosis  m  the  'perineal  operation, 
supposing  that,  as  far  as  possible,  suitable  cases  are  selected 
— that  is  to  say,  cases  in  which,  from  the  locality,  mobility, 
and  general  nature  of  the  growth,  the  surgeon  believes  its  total 
removal  from  the  perineum  possible. 

Great  difficulty  attaches  to  reasoning  from  statistics  ; 
unless  the  character  of  each  case  is  clearly  reported,  there 
is  the  great  probability  that,  in  many  instances,  attempts 
at  removal  will  have  been  made  where  the  untoward  results 
sufficiently  indicate  that  operation  should  not  have  been 
performed.  I  have,  however,  been  able  to  collect  statistics 
from  two  sources  which  seem  to  supply  the  requisite  data. 
They  are  those  of  Cripps  of  London,  and  Czerny  of  Heidel- 
berg, both  surgeons  of  recognised  repute,  and  whose  cases 
are  carefully  selected. 

Cripps '  excised  the  rectum  from  the  perineum  in  38 
cases  ;  3  died  and  35  recovered  from  the  immediate  effects 
of  the  operation,  giving  a  mortality;  of  7'8  per  cent.  The 
following  shows  the  subsequent  history  of  the  cases  that 
recovered : 

In    7  no  reliable  subsequent  history. 

In  10  recurrence  occurred  within  one  year. 

In    5  recurrence  occurred  between  the  first  and  third  year. 

In    ]  death  occurred  a  year  later  without  recurrence. 

In    1  no  recurrence  after  the  lapse  of  eighteen  months. 


In  11  no  recurrence  in 


Out  of  this  list  of  cases  there  were  therefore  seven  which  had 
lived  beyond  the  usual  three-year  limit ;  among  these,  how- 
ever, were  three  in  which  some  recurrence  took  place,  but 
which  in  each  was  successfully  removed. 

'  Brit.  Med.  Journ.  1892,  vol.  i.  p.  1277. 

S  S 


3 

under  1 

year 

1  after 

2 

years 

1 

3 

2 

4 

1 

5 

2 

6 

1 

12 

626  THE   RECTUM 

Czerny's  cases  ^  are  collected  from  the  six  years  between 
1886  and  1891,  and  were  published  by  Schmidt  in  1892.  It  is 
not  therefore  possible  to  give  the  com]3lete  number  of  cases 
which  might  pass  beyond  the  three-year  limit,  nor  to  state 
how  much  longer  than  the  period  included  any  particular 
case  which  had  passed  the  cure-limit  might  live. 

These  six  years  embrace  thirty-two  operations  by  the 
perineal  method  with  one  death ;  thus  giving  a  mortality  of 
3*1  per  cent,  as  directly  the  result  of  the  operation.  At  the 
time  at  which  the  report  was  made  there  were  ten  of  these 
patients  living. 

1  patient   5|  years  after  the  operation 
3  patients  5        „         „ 
1  patient   3^      „        „ 

1  ),         H  year       „ 

2  patients  1        ,,         „ 
1  patient      3      „         )> 

Of  sixteen  cases  which  had  died,  the  duration  of  their  life 
after  the  operation  amounted  on  an  average  to  two  years,  the 
longest  duration  was  four  years.  Nothing  was  known  about 
four  patients. 

Lovinsohn's  cases  ^  are  collected  from  Czerny's  Heidelberg 
clinic  between  the  years  of  1883  and  1886,  and  are  sixteen 
in  number ;  they  were  publithed  in  1893.  One  patient 
died  of  collapse,  the  direct  result  of  the  operation,  giving  a 
percentage  mortality  of  6-2.  Nine  lived  for  two  years  a,nd 
longer,  the  exact  periods  being 

2  patients  lived  2    years 

1  patient       „      2g- 

2  patients     ,,     4 
1  patient       ,,      4| 
1        ,,  »      6| 

1  M  „       7 

1        „  „      8J 

Of  these  nine  cases,  all  died,  with  the  exception  of  twOj  of  a 
recurrence  of  the  disease.  The  two  exceptions  are  those  of 
6f  years  and  8|  years,  where  it  is  noted  that  the  patients  were 
alive  and  free  from  any  sign  of  return.     In  one  of  the  cases 

'  Beitrage  zur  klin.  Chir.  1892,  Bd.  ix.  Heft  ii.  p.  409. 
2  Ibid.  1893,  Bd.  x.  p.  223. 


CARCINOMA— PROGNOSIS  627 

which  hved  for  four  years,  the  recurrence  took  place  in  the 
liver. 

The  inferences  to  be  derived  from  these  statistics  are  (1) 
that  the  operation  itself  is  not  a  fatal  one,  the  mean  percentage 
of  mortality  of  these  two  operators  being  5*3  :  (2)  that  pro- 
longation of  life  is  possible  in  suitably  selected  cases  :  (3)  that 
extirpation  of  the  disease  with  permanent  cure  is  comparatively 
rare. 

Prognosis  in  the  sacral  operation  is  in  many  respects  much 
more  difficult  and  much  graver  than  in  the  case  of  the  perineal 
operation.  In  the  first  place  the  operation  deals  with  disease 
in  a  part  of  the  bowel  where  there  is  much  difficulty  in  de- 
ciding the  character  and  extent  of  the  growth,  and  therefore 
the  possibihty  of  its  complete  removal ;  this  feature  is  well 
illustrated  in  my  own  case,  narrated  in  full  below,  where 
it  was  not  until  the  performance  of  the  operation,  and  the 
actual  exposure  of  the  seat  of  the  disease,  that  the  extent  to 
which  it  had  involved  the  sacral  glands  was  discovered.  In 
the  second  place  the  severity  of  the  operation  removes  that 
assurance  of  immediate  success  which  as  a  rule  attends  the 
perineal  excision.  Still  further,  it  is  impossible  to  foresee  how 
far  the  result  of  the  operation  may  correspond  to  what  was 
aimed  at ;  and  how  far  the  subsequent  conditions  may  even 
be  aggravated  by  the  operation. 

The  question  may  be  first  asked,  What  are  the  results 
which  may  follow  this  method  of  excision  apart  from  those 
connected  directly  with  the  operation  and  those  concerning 
the  possibility  of  effecting  a  cure  ? 

The  most  favourable  result,  apart  from  the  question  of 
total  removal  of  the  disease,  and  that  unfortunately  least 
often  obtained,  is  complete  control  of  the  bowel.  How  this 
may  be  effected  independently  of  the  retention  of  the  normal 
sphincters  will  be  described  under  the  section  of  operations. 
Suffice  it  to  say  here,  however,  that  in  by  far  the  large  pro- 
portion of  cases  there  is  incontinence  of  faeces  to  a  greater  or 
less  extent.  In  many  instances,  faecal  fistulse  form  in  some 
part  of  the  posterior  wound ;  in  not  a  few,  also,  these  fistulas 
enlarge  until  they  form  the  sole  exit  for  the  discharge.  Again, 
it  may  be  found,  after  the  removal  of  the  growth,  that  it  is 
impossible  to  retain  the  anal   section   of  the    gut,  or   even 

s  s  2 


628  THE   EECTUM 

to  bring  down  sufficiently  the  upper  segment  in  order  to  attach 
it  below.  In  such  cases  a  sacral  anus  has  to  be  established. 
As  a  last  remote  effect  may  be  mentioned  cicatricial  contrac- 
tion, and  consequent  obstruction. 

Following  more  directly  upon  the  operation  are  results 
dependent  upon  septic  infection  of  the  wound.  These,  fortu- 
nately, have  not  been  of  a  very  frequent  character ;  and, 
although  possible,  they  need  not  be  introduced  as  arguments 
of  much  cogency  against  its  performance. 

Now,  as  regards  the  mortality  of  the  operation  and  the 
possibility  of  obtaining  a  cure. 

In  Czerny's  series  of  36  cases  operated  upon  by  the 
sacral  method  there  were  7  deaths  due  directly  to  the 
operation,  giving  a  mortality  of  19-4  per  cent.  There  were 
living  at  the  time  the  report  was  made,  eighteen.     Of  these, 

/3  after  2|  years 
6    1     „     2i      „ 
(2     „     2        „ 
12  from  1|  year  to  5  months. 

Nine  bad  died  from  recurrence,  metastases,  &c.  within  the 
period  over  which  the  series  extends  — that  is,  six  years.  Some 
of  these  cases  are  reported  as  being  in  good  health  and  as  having 
returned  to  their  accustomed  work. 

From  this  series  it  will  be  seen  that  there  is  no  record  of 
any  having  passed  the  three-year  limit,  although  it  is  quite 
possible  that  some  may  have  done  so  by  this  time. 

The  question  regarding  this  operation  now  comes  to  be 
one  of  determining  whether  the  good  that  it  can  effect  suffi- 
ciently outweighs  the  untoward  results  that  frequently  follow  ; 
in  other  words,  does  the  prolongation  of  life  and  the  relief  of 
suffering  more  than  compensate  for  the  lives  it  shortens, 
and  the  often  additional  troubles  it  causes  ?  It  need  hardly 
be  said  that  the  question  is  one  of  extreme  difficulty  ;  for 
even  if  it  could  be  shown  that  Czerny's  results  gave  a  balance 
in  favour  of  the  operation  in  supposed  suitable  cases,  it  far 
from  follows  that  less  experienced  operators,  in  such  a  grave 
and  comparatively  difficult  operation,  would  obtain  like  good 
results.  Indeed,  if  one  may  judge  from  isolated  instances 
recorded — and  it  may  reasonably  be  accepted  that  it  is  mostly 
the  successful  cases  which  are  published — results  argue  rather 


CARCINOMA— PROGNOSIS  629 

against  than  for  the  operation.  And  as  regards  opinions, 
surgeons,  in  this  country  at  least,  are  not  disposed  to  give  it 
more  than  a  very  scanty  recognition,  and  but  a  very  Hmited 
apphcation. 

That,  however,  it  is  possible  to  remove  the  disease  entirely 
and  leave  the  patient  in  comparative  enjoyment  of  health  and 
with  the  ability  to  do  his  ordinary  work  in  daily  life,  is  a 
sufficient  justification  for  the  operation  |)er  se.  It  only  re- 
mains for  the  surgeon  to  consider,  in  attempting  to  gain  such 
a  desirable  end,  whether  the  case,  in  the  first  place,  ajDpears 
to  bim  a  really  suitable  one ;  and  whether,  in  the  second,  he 
is  prepared  to  recommend  it  to  his  patient  in  the  face  of  the 
various  risks  and  the  untoward  results  which  are  not  only 
possible,  but  proportionately  probable  to  the  limited  experience 
he  may  have  had  in  performing  the  operation. 

Before  passing  from  the  prognosis  connected  with  these 
two  operations,  the  perineal  and  the  sacral,  a  few  facts  brought 
out  in  Lovinsohn's  paper  are  worthy  of  note.  The  author 
deals  with  the  results  of  these  two  operations  combined,  and 
treats  collectively  of  the  cases  operated  upon  in  Czerny's 
Heidelberg  clinic  between  the  years  1878  and  1891,  thus 
including  Heuck's  published  statistics  between  1878  and  1882, 
and  Schmidt's  between  1886  and  1891,  his  own  series  filling 
up  the  gap  of  three  years  between  1882  and  1886. 

There  were  109  radical  operations,  with  10  deaths.     Of 

the  99  surviving  patients, 

21  lived  for  2  years  or  longer 

-I"     ))        ))   "      ))      ))       )> 
13  4 

O  ))  ))       "  ))  ))  )) 

Four  patients  lived  for  13|,  11^,  8|,  and  6|  years  respectively 
after  the  operation. 

It  is  interesting  to  note  that  while  we  in  Britain  fix  three 
years  as  the  period  for  considering  a  patient  as  cured  if  no 
return  is  observed,  and  that  in  Germany  the  period  is  fixed  a 
year  earlier,  these  statistics  unmistakably  show  that  the  limit 
is  far  from  being  a  reliable  one.  Thus  a  return  of  the  disease 
was  observed  after  periods  of  four,  six  and  a  half,  and  seven 
years.  Volkmann  also  observed  recurrences  after  periods  of 
three,  five,  and  six  years,  and  in  one  case  in  the  liver  after 


630  THE   RECTUM 

eight  years.  Hildebrand  is  also  reported  as  having  seen 
several  recurrences  in  from  three  to  four  and  a  half  years 
after  operation. 

Another  interesting  feature  which  these  statistics  bring 
out  is  the  almost  constant  lack  of  any  power  of  faecal  conti- 
nence. In  only  two  cases  is  it  noted  that  there  was  complete 
continence,  and  in  these  the  anus  was  not  removed  ;  in  the 
remainder  there  was  either  no  continence,  or  only  slight  power 
of  retention  when  the  motions  were  firm. 

Prognosis  in  regard  to  the  formation  of  an  artificial  anus  is 
less  difficult  to  give  than  in  the  preceding  cases,  for  the  opera- 
tion no  longer  concerns  the  question  of  cure,  but  simply  that 
of  relief.  Life  may  also  be  prolonged,  in  so  far  as  it  is  affected 
by  the  relief  to  suffering,  and  the  warding  off  of  dangerous 
complications. 

The  operation,  whether  performed  in  the  groin  or  in  the 
lumbar  region,  is  of  such  a  simple  and  safe  character,  that  of 
itself  it  need  not  be  considered  as  affecting  the  prognosis. 
When  it  has  proved  fatal  it  has  usually  been  in  cases  of  extreme 
gravity,  such  as  in  operations  upon  patients  far  gone  with 
symptoms  of  intestinal  obstruction. 

In  forecasting  the  result  of  the  operation,  it  may  be  said 
to  give  immediate  relief  in  most  instances,  by  lessening  the 
pain  and  removing  the  obstruction ;  but  it  adds  the  incon- 
venience and  discomfort  necessarily  connected  with  the  in- 
voluntary exit  of  fseces  in  the  groin  or  in  the  loin.  As  a  rule 
patients  are  ready  to  face  these  inconveniences  rather  than 
endure  the  suffering  which  comes  of  inability  to  get  a  proper 
movement  of  the  bowels. 

As  regards  the  effect  an  artificial  anus  has  in  prolonging 
life,  much  must  depend  upon  the  nature  of  the  disease  and 
the  condition  of  the  patient.  By  the  performance  of  the 
operation  upon  a  patient  on  the  verge  of  death  from  obstruc- 
tion, life  is  not  only  prolonged,  but  actually  saved.  On 
the  other  hand,  to  make  an  anus,  merely  because  a  patient 
has  malignant  disease,  from  which  he  neither  suffers  nor  is 
inconvenienced,  would  be  to  add  a  discomfort,  without 
probably  in  any  way  checking  the  onward  progress  of  the 
tumour.  If,  however,  the  patient  is  slowly  sinking  from 
the  pain  and    trouble  associated  with  the  passage  of  faeces 


CARCINOMA— TREATMENT  (531 

over  the  part,  there  is  little  doubt  that  life  will  be  S2:>arecl  for 
a  longer  period  than  if  the  operation  had  not  been  performed. 
In  a  case  recorded  by  Allingham,'  where  a  mass  filled  the 
pelvis,  the  patient  lived  four  and  a  half  years  after  the  operation. 


CHAPTER   LXXVI 

CARCINOMA  (continued),     treatment,     sarcoma 

Treatment. — Sufficient  has  been  said  regarding  the  patho- 
logy, symptoms,  and  prognosis  of  the  disease  to  indicate  how 
largely  treatment  must  depend  upon  the  circumstance  of 
each  individual  case.  It  is  possible,  however,  to  simplify  the 
discussion  of  the  subject  by  making  a  primary  division  of  the 
cases  to  be  treated  into  those  which  are  operable  and  those 
which  are  not,  and  then  subdividing  the  former  into  cases 
suitable  for  extirpation  and  those  best  fitted  for  the  formation 
of  an  artificial  anus. 

'Treatment  of  non-operahle  cases. — In  this  class  of  cases  are 
included  all  those  which  are  considered  too  advanced  for  any 
purpose  to  be  served  by  subjecting  the  patient  to  an  operation, 
and  those  who  refuse  to  have  anything  done. 

The  treatment  necessary  concerns  the  relief  of  the  sym- 
ptoms by  palliative  or  conservative  measures.  Prominent 
among  these  must  be  the  regulation  of  the  bowel  and  the 
adoption  of  a  suitable  diet.  Mild  laxatives  should  be  ad- 
ministered. A  morning  draught  of  one  of  the  aperient  waters 
is  often  of  much  service  in  this  respect.  In  diet  nothing 
should  be  taken  which  is  liable  to  irritate  the  bowel  or  tend 
to  produce  constipation. 

"When  there  is  much  offensive  and  irritating  discharge  from 
the  diseased  part,  cleanliness  is  of  much  importance,  not  only 
in  lessening  the  deleterious  effects  such  discharges  have  by 
absorption  upon  the  general  health  of  the  patient,  but  in  pre- 
venting the  excessively  painful  fissures  and  excoriations  which 
form  in  and  around  the  anus.  Injections  of  warm  antiseptic 
solutions  should  be  frequently  used.  Condy's  fluid,  largely 
diluted,  acts  as  a  powerful  deodoriser  ;  a  solution  of  naphthol, 
about  four  grains  to  the  quart,  is  recommended  by  Beaumetz."^ 

'  r.  300.  -  Mathews,  Diseases  of  the  Eccltiin  and  Anus,  p.  389. 


632  THE   RECTUM 

A  sitz  bath  is  also  serviceable  ;  and  the  occasional  insertion 
of  an  iodoform  suppository  is  sometimes  useful. 

The  relief  of  pain  is  sometimes  of  paramount  importance, 
and  should  be  treated  with  some  consideration.  The  adminis- 
tration of  opium  and  its  preparations,  either  hypodermically 
or  as  suppository,  will  in  most  instances  give  the  required  re- 
lief ;  but  if  its  administration  is  commenced  at  an  early  period 
of  the  disease,  the  original  dose  soon  begins  to  fail  in  produc- 
ing its  effect ;  so  that  while  the  pain  increases,  the  influence 
of  the  drug  diminishes.  Hence,  to  give  the  necessary  relief, 
the  amount  has  to  be  increased.  The  gradual  addition  to  the 
quantity  administered  is  liable  to  produce  a  craving  for  the 
drug,  and  this  becomes  so  intense  in  some  cases  that  patients 
have  been  known  to  confess  that  the  suffering  connected  with 
the  insatiable  desire  for  the  drug  was  worse  than  that  asso- 
ciated with  the  disease.  To  guard  against  such  a  result,  opium 
should  be  kept  as  a  last  resource,  and  then  when  given,  only 
the  smallest  dose  capable  of  producing  the  desired  effect.  This 
rule  also  applies  to  every  addition  that  is  made  to  the  strength 
of  the  dose.  Among  sedatives  which  naay  be  locally  applied 
for  the  relief  of  pain  are  cocaine,  hyoscyamine,  and  belladonna. 
Treves  ^  adopts  the  following  formula :  Begin  with  supposi- 
tories containing  cocaine ;  when  these  cease  to  be  effectual, 
replace  them  by  suppositories  containing  hyoscyamine  ;  and 
when  these  fail,  others  containing  opium  and  belladonna  are 
tried.     Lastly,  morphia  suppositories  are  given. 

Two  other  measures  must  be  considered,  which  occupy  a 
position,  however,  somewhat  between  the  purely  conservative 
and  the  purely  operative  ;  these  are  relief  of  the  obstruction 
by  division  of  the  stricture  either  partially  or  completely,  and 
curetting  or  scooping  away  the  tumour  when  of  a  sufficiently 
soft  character.  Neither  method  is  likely  to  appeal  with  much 
force  to  surgeons  ;  nevertheless  it  is  right  to  indicate  that 
such  a  good  authority  as  William  Allingham  advises  both  in 
certain  cases,  and  has  practised  them  with  good  effect.  Cases 
suitable  for  '  scooping '  are  those  which  are  clinically  de- 
signated '  encephaloid  ; '  to  be  effectual  and  avoid  much  bleed- 
ing, the  tumour  must  be  well  *  scooped  '  away  until  more  or 
less  normal  tissue  is  reached. 

'  Clin.  Journ.  1893,  vol.  i.  p.  222. 


CARCINOMA— TREATMENT  633 

Partial  division  of  the  stricture,  by  incising  it  in  one  or 
two  places,  must  be  followed  up  by  the  use  of  bougies. 

Complete  division  or  the  performance  of  linear  or  posterior 
proctotomy  will  give  temporary  relief,  but  inasmuch  as  the 
operation  involves  division  of  the  sphincters,  fgecal  inconti- 
nence must  follow. 

Trcatmtnt  of  operabh  cases. — Which  of  the  two  operations 
should  be  performed  in  any  case — that  is  to  say,  extirpation  or 
the  formation  of  an  artificial  anus— must  be  decided  solely  on 
grounds  of  whether  or  not  it  is  considered  possible  to  remove 
the  whole  primary  seat  of  the  disease. 

When  the  question  concerns  the  performance  of  the 
perineal  o^Deration,  it  is  not  usually  very  difficult  to  decide. 
In  these  cases  the  seat  of  the  disease  is  open  to  careful  in- 
vestigation, and  it  is  approximately  possible  to  determine  the 
extent  of  the  bowel  involved,  both  superficially  and  deeply. 
When  the  growth  is  localised  or  the  stricture  limited,  removal 
may  be  considered  the  proper  course  to  adopt  if  in  neither 
case  there  is  any  indication  of  fixation  of  the  part  to  the 
deeper  structures.  Thus  if  it  is  fixed  to  the  sacrum,  or  to  the 
bladder,  prostate,  or  urethra  in  the  male,  and  the  vagina  or 
uterus  in  the  female,  the  case  is  not  a  suitable  one  for  extir- 
pation unless  the  surgeon  is  prepared  to  go  to  great  lengths 
and  freely  remove  all  parts  which  appear  involved,  heedless 
of  the  consequences  which  may  result,  so  long  as  the  disease 
is  removed.  It  may,  however,  well  be  doubted  whether  such 
mutilation  is  justified,  considering  the  wretched  state  in  which 
the  patient  must  be  left  and  the  extreme  improbability  of 
eradicating  the  disease. 

Wlien  the  question  is  one  concerning  the  performance  of 
the  sacral  operation,  much  depends  not  only  upon  the  more  or 
less  conjectural  opinion  regarding  the  nature  and  extent  of  the 
growth,  but  upon  the  general  condition  of  the  patient.  The 
operation  is  a  severe  one,  and  the  shock  often  considerable ; 
hence,  while  the  diseased  i)art  may  seem  suitable  for  removal, 
the  patient's  strength  may  not  be  deemed  equal  to  the  possible 
loss  of  blood  and  the  shock  which  its  performance  will  probably 
entail. 

There  are  certain  other  conditions  which  may  be  con- 
sidered as  practically  inhibitory  to  the  performance  of  extirpa- 


634  THE   RECTUM 

tion  by  either  method.  These  are  the  existence  of  obviously 
enlarged  glands,  either  in  the  sacrum  or  in  the  abdomen, 
along  the  lumbar  spine  :  marked  enlargement  of  the  liver,  with 
possibly  ascites :  advanced  disease,  as  shown  by  a  marked 
cachexia  and  general  loss  of  flesh  and  strength  :  fistulous 
c'jmmunication  with  bladder,  urethra,  vagina,  or  uterus  ;  and 
in  cases  of  acute  intestinal  obstruction  when  urgent  relief  is 
required. 

If  extirpation  is  not  deemed  advisable  from  any  of  the 
causes  above  given,  the  question  then  becomes  one  regarding 
the  formation  of  an  artificial  anus.  In  cases  of  acute  ob- 
struction or  recto- vesical  fistulse,  an  artificial  anus  should  be 
made  ;  but,  short  of  such  complication,  the  operation  is  one  to 
be  selected  by  the  patient  rather  than  urged  by  the  surgeon. 
The  possibility  of  relief  and  prolongation  of  life,  as  well  as  the 
converse  possibilities ;  and  the  additional  inconveniences  of  an 
incontrollable  ftecal  orifice  must  all  be  honestly  placed  before 
the  patient,  with  such  opinions  as  the  surgeon  may  feel  justi- 
fied in  expressing  from  his  experience,  and  his  knowledge  of 
the  nature  and  extent  of  the  disease. 

Case  CXI. — Posterior  proctectoyny  (Kraske).  Becovery  with  sacral  anus. 
(Abstract  from  report  taken  by  Dr.  Symington.) 

J.  E.,  aged  35  years,  has  all  his  life  suffered  from  constiijation  ;  five 
months  before  admission  to  the  infirmary  he  first  noticed  blood  in  his 
motions.  His  difficulty  in  defecation  has  been  gradually  increasing,  and 
recently  he  has  been  obliged  to  take  aperients  in  order  to  get  a  movement 
of  his  bowels.  Pain  is  usually  felt  above  the  umbilicus  before  defecation, 
but  the  act  itself  does  not  cause  undue  inconvenience,  unless  the  motions 
are  more  than  usually  costive.  He  has  lost  strength  and  body  weight, 
and  his  appetite  has  become  much  impaired.  The  man  himself  is  well 
built  and  muscular,  with  ruddy  complexion,  and  no  marked  evidence  of 
being  much  affected  by  the  disease.  A  digital  examination  of  the  rectum 
reveals  a  well-marked  tight  stricture,  about  two  inches  up  from  the  anus. 
It  is  somewhat  irregular,  and  its  upper  limit  cannot  be  gauged.  The 
patient  was  prepared  for  operation  by  the  administration  of  an  ounce  of 
castor  oil  the  day  before. 

Oiieration. — With  the  assistance  of  Drs.  Grant  Andrew,  Paterson,  and 
Symington  posterior  proctectomy  was  performed  (Kraske).  After  exposing 
the  rectum  a  transverse  incision  was  made  about  an  inch  above  the  anus, 
and  the  upper  portion  stripped  upwards  until  it  could  be  severed  above 
the  stricture.  Much  adhesion  existed  between  the  bowel  and  the  sacrum 
at  the  upper  part,  and  this  was  found  to  be  due  to  a  mass  of  tumour 
grontli  (probably  glandular),  the  remo\'al  of  >vhich  constituted  the  most 


CARCINOMA  635 

difficult  part  of  the  operaticn.  After  removal  of  the  Lowel  it  was  ftjuiul 
that  the  peritoneal  cavity  had  been  opened ;  it  was  closed  by  suture. 
The  upper  portion  of  the  bowel  was  now  brought  down,  and  its  edges 
stitched  to  the  edges  of  the  anal  part  of  the  gut  below.  This  was  effected 
without  any  tension  of  the  sutured  edges.  Fseces  having  escaped  into 
the  wound,  it  was  freely  irrigated  and  then  stuffed  with  iodoform  gauze. 
xV  large-sized  rubber  tube  was  introduced  into  the  anus,  and  pushed  well 
up  above  the  sutured  margin.  The  haemorrhage  was  very  free  at  every 
stage  of  the  operation,  the  bleeding  being  mostly  of  a  parenchj-matous 
character,  and  stopped  by  pressure. 

In  the  afternoon,  about  five  hours  after  the  operation,  the  patient  was 
attacked  with  severe  gi'iping  pain  in  the  hypogastrium.  The  dressings 
were  found  soiled  with  faeces,  which  proved  to  be  passing  freely  from  the 
bowel  between  the  sutured  extremities  and  into  the  wound. 

The  patient  made  an  uninterrupted  recovery,  gaining  strength,  and 
putting  on  flesh.  The  fistula  finally  assumed  the  condition  of  a  sacral 
anus. 

The  tumoiir,  when  examined  microscopically,  was  shown  to  be  of  the 
usual  tj'pe  of  columnar-celled  carcinoma.  (A.  Ernest  Maylard,  '  Trans. 
Path,  and  Clin.  Sec,  Glasgow,  1895,  vol.  v.  p.  59.) 

The  case  presents  two  features  of  special  interest.  One 
has  ah'eady  been  refeired  to,  that  regarding  the  extent  of  the 
disease  towards  the  sacrum,  which  was  not  discovered  until 
the  bowel  was  separated  from  its  connection.  The  other  has 
reference  to  the  inefiicient  emptying  of  the  bowel  by  an  aperient 
before  operating.  This  will  be  noticed  again  in  describing  the 
methods  of  operation.  It  teaches  that  when  it  is  not  possible 
from  the  tightness  of  the  stricture  to  efficiently  clear  the 
bow^el  above,  a  preliminary  sigmoidostomy  should  be  per- 
formed. 

Case  CX.11.  —Carcinoma  of  rechtm  :  sigmoid  anus.  Becovery. 
(Abstract  of  report  taken  by  Dr.  Alexander  MacLennan.) 
W.  McC,  aged  30,  a  ploughman,  was  admitted  into  the  Victoria 
Infirmary,  Glasgow,  on  July  3,  1895.  About  fourteen  months  previously 
he  commenced  to  be  troubled  with  constipation,  and  noticed  that  blood 
occasionalh'  passed  either  before  or  during  the  motion.  To  obtain  a  move- 
ment of  his  bowels,  he  always  found  it  necessary  to  take  aperient  medicine. 
No  pain  was  noticed  at  the  earlier  period  of  his  disease,  and  he  attributed 
his  condition  to  the  presence  of  piles.  About  four  months  back,  pain  was 
first  felt,  and  was  then  like  a  weight  in  his  bowel.  It  has  now  come  to 
be  paroxysmal  in  character,  and  he  has  to  do  all  he  can  to  retain  himself 
from  crying  out.  It  is  worse  at  night  and  on  going  to  stool.  In  addition 
he  has  a  sensation  of  burning  in  the  bowel.  He  also  complains  of  shoot- 
ing pains  in  his  legs,  especially  in  the  left  leg,  and  in  the  small  of  his 
back.     Tlie  patient  looks  a  strong  healthy  man,  but  states  that   since 


636  THE   RECTUM 

Ajiril  last  he  has  been  losmg  flesh.  He  does  not  care  for  his  food,  and 
feels  very  weak.  There  is  no  apparent  enlargement  of  the  liver.  Exami- 
nation of  the  rectum  reveals  a  dilated  cavity,  and  the  finger  impinges 
against  an  obstruction  which  proves  to  be  an  annular  stricture ;  the  gut 
also  presents  a  '  bossy  '  sensation  in  the  neighbourhood  of  the  disease. 
The  finger  readily  passes  through  the  central  opening,  and  the  thickness 
of  the  growth  as  thus  determined  is  probably  about  an  inch.  The  tumour 
commences  about  two  inches  and  a  half  from  the  anus.  The  bowel 
appears  movable  in  front  with  no  implication  of  the  prostate  or  bladder. 
Behind,  it  is  firmly  fixed  to  the  sacrum,  no  mobility  of  the  parts  being 
possible. 

On  July  24,  after  ten  days'  inability  to  get  a  proper  movement  of  the 
bowels,  the  patient  was  advised  to  have  an  artificial  anus  made.  The 
case  at  this  time  was  not  urgent,  and  there  was  no  abdominal  distension  ; 
but  the  prospect  not  being  hopeful  from  the  rate  at  which  the  growth 
was  increasing,  and  the  continuance  of  obstruction,  it  appeared  wiser  to 
open  the  bowel  rather  than  to  delay  doing  so  until  compelled.  A  left 
sigmoid  anus  was  made,  but  the  bowel  not  opened  until  the  following 
daj',  when  the  onset  of  obstructive  symptoms  necessitated  the  giving  of 
immediate  relief. 

The  patient  left  the  infirmary  about  two  months  after  the  operation, 
greatly  improved  in  health,  and  in  every  respect  satisfied  with  the  relief 
he  had  experienced  since  the  operation.  (A.  Ernest  Maylard,  Victoria 
Infirmary,  Clinical  Eeports,  1895,  No.  1113.) 

Sarcoma. — Sarcoma  is  rarely  met  with  as  one  of  the  forms 
of  malignant  disease  attacking  the  rectum.  Excluding  such 
exceptional  and  possibly  doubtful  instances  as  that  described 
as  '  ossifying  cancer,'  already  referred  to,  almost  every  recorded 
case  illustrates  the  melanotic  type  of  the  growth.  Heaton 
showed  at  the  London  Pathological  Society  ^  a  specimen  of  a 
tumour  removed  from  the  right  side  of  the  rectum.  It  con- 
f-isted  of  a  dark-coloured  bleeding  mass  about  the  size  of  a 
small  orange.  After  its  removal  another  mass  was  felt  behind 
the  rectum,  higher  up,  between  the  bowel  and  the  sacrum  and 
beyond  reach  of  removal.  Examined  microscopically,  the 
growth  was  found  to  consist  of  round  cells  containing  mela- 
notic pigment  in  variable  quantities.  Bowlby,  at  the  same 
meeting  of  the  Society,  referred  to  a  similar  case  which  had 
come  under  his  observation  ;  and  Pitt  pointed  out  that  the 
late  Hilton  Fagge  had  described  the  rectum  as  being  one  of 
the  primary  seats  of  melanotic  growth.  Lange  ^  exhibited  a 
specimen  of  the  disease  at  the  New  York  Surgical  Association. 

'  Trans.  1894,  vol.  xlv.  p.  85. 

"  Netv  York  Med.  Joiirn.  1887,  vol.  xlv.  p.  274 


PROLAPSE  637 

Cooper  and  Edwards  '  refer  to  ten  cases  collected  by  Nepveu, 
and  to  one  published  by  Ball. 

A  case  of  spindle-celled  sarcoma  is  recorded  by  Le^Yis.^  A 
man  aged  43  years  had  for  three  years  suffered  from  in- 
creasing difficulty  in  defecation.  When  first  seen,  a  tumour 
about  the  size  of  a  foetal  head  was  felt  in  the  rectum.  By  an 
effort  on  the  part  of  the  patient  it  could  be  made  to  appear 
outside  the  sphincter.  The  tumour  arose  from  submucous 
tissue  and  was  covered  by  mucous  membrane.  It  was  easily 
enucleated. 


CHAPTER   LXXVII 

PROLAPSE 

The  protrusion  beyond  the  anus  of  any  portion  of  the  bowel 
constitutes  a  prolapse ;  and  inasmuch  as  this  protrusion  may 
vary  between  a  slight  eversion  of  the  mucous  membrane  and 
a  complete  turning  out  of  the  whole  rectum,  two  terms  have 
been  introduced  to  signify  the  more  or  less  opposite  extremes. 
Thus,  when  only  the  mucous  membrane  is  everted  for  a  short 
distance,  the  condition  is  termed  jprolapsus  ani ;  and  when  the 
whole  bowel  is  everted  it  is  called  procidentia  recti.  Between 
these  two  extremes,  however,  there  is  every  gradation  ;  and 
in  order  to  include  those  forms  which  do  not  come  strictly 
under  either  of  the  two  already  given,  a  division  is  sometimes 
made  into  partial  prolapse  and  complete  prolapse  of  the 
rectum. 

The  condition  may  be  met  with  at  any  period  of  life,  but 
is  more  frequent  at  the  two  extremes.  In  the  young  the 
various  degrees  of  partial  prolapse  are  mostly  seen ;  while 
in  the  old  the  prolapse  tends  towards  the  complete  form. 

The  smaller  the  length  of  the  prolapse  the  more  likely  is 
it  to  consist  simply  of  mucous  membrane,  while  the  greater 
its  length  the  greater  the  probability  that  all  the  coats  of  the 
bowel  will  be  everted  ;  and  if  the  protrusion  be  of  sufficient 
length,  a  pouch  of  the  peritoneal  cavity  will  exist  between 
the  outer  and  inner  tube  in  front,  or,  in  extreme  cases,  the 
whole  way  round. 

'  P.  210.  -  Boston  Med.  and  S:irg.  Journ.  1883,  vol.  cix.  p.  620. 


638  THE   RECTUM 

As  indicating  the  comparative  frequency  with  which  the 
affection  is  met  with  in  children,  Logan  ^  reports  that  at  the 
Liverpool  Infirmary  for  Children  about  thirty-two  cases  are 
seen  per  annum. 

Causes  of  prolapse, — In  the  majority  of  instances  the  pro- 
trusion is  indirectly  due  to  causes  which  induce  an  exaggeration 
of  the  normal  ejaculatory  functions  of  the  rectum.  In  addition 
there  are  certain  predisposing  influences,  both  normal  and 
pathological,  which  materially  aid  in  allowing  these  unnatural 
exciting  causes  to  produce  their  effect.  Thus  in  young 
children  the  rectum  has  less  support  than  in  the  adult,  due  in 
part  to  the  absence  of  any  well-marked  curve  in  the  sacrum 
and  to  the  natural  elasticity  of  the  tissues.  Among  patho- 
logical influences  are  such  as  produce  a  want  of  tone  in  the 
parts,  as  for  instance  debility  from  any  cause.  The  effect  of 
these  constitutional  conditions  is  (1)  to  produce  a  weakening 
of  the  muscular  coat  of  the  bowel,  the  sphincters,  and  the 
slinglike  and  supporting  action  of  the  levator  ani,  partly  as 
the  result  of  lack  of  nerve  power  and  partly  from  wasting  of 
the  muscle  tissue :  (2)  to  remove  the  padlike  support  of  the 
fat  in  the  ischio-rectal  fossae  ;  and  to  weaken  the  connective 
tissues  which  unite  the  mucous  membrane  to  the  muscular 
coat. 

The  causes  which  bring  about  undue  action  of  the  rectum 
in  children  are  whooping  cough,  diarrhoea,  intestinal  worms,  the 
presence  of  a  rectal  polypus,  phimosis,  stone  in  the  bladder, 
and  the  prejudicial  habit  of  allowing  a  child  to  sit  for  too  long  a 
time  upon  the  stool  after  the  required  movement  of  the  bowels 
has  taken  place.  As  regards  diarrhoea,  Logan  remarks  that 
prolapse  is  most  frequent  at  the  ages  and  at  the  times  of  the 
year  when  this  condition  is  most  prevalent. 

In  the  case  of  adults  similar  causes  may  be  present,  such 
as  rectal  polypus  and  vesical  calculus  ;  in  addition,  however, 
there  are  causes  peculiar  to  adult  life  and  advancing  age,  such 
as  chronic  constipation,  haemorrhoids,  urethral  stricture,  and 
enlarged  prostate. 

The  formation  of  a  prolapse  is  sometimes  sudden,  but  more 
frequently  it  is  gradual.  When  arising  suddenly,  it  is  generally 
traceable  to  some  excessive  straining  effort.     When  gradual, 

'  LivcriJool  Mech-Chir,  Joiiin.  1891,  p.  380. 


PROLAPSE  639 

the  mucous  membrane  prolapses  in  the  first  place,  and  then, 
by  its  constant  and  increasing  dragging  effect,  it  causes 
the  muscular  tunic  to  follow,  and  a  complete  eversion  is  pro- 
duced. 

Symptoms.— It  is  somewhat  difficult,  if  not  strange,  to  speak 
of  the  symptoms  of  what  is  in  itself  practically  only  a 
symptom  ;  for,  as  above  shown,  the  condition  is  almost  in- 
variably the  result  of  some  definite  cause,  which  must  be 
successfully  dealt  with  in  the  first  place  if  the  prolapse  is  to 
be  prevented.  However,  if  the  prolapse  is  secondary  to  some 
other  trouble,  it  nevertheless  creates  obvious  troubles  and 
inconveniences  directly  traceable  to  its  own  existence. 

The  appearance  of  a  prolapse  is  not  likely  to  be  mistaken 
after  careful  examination  of  the  part.  When  the  protrusion 
is  only  slight,  it  may  resemble  the  projection  of  internal 
haemorrhoids,  or  a  polypus ;  but  neither  of  them  need  mis- 
lead if,  as  stated,  the  part  he  carefully  examined  by  the  eye 
and  the  finger. 

A  typical  protrusion  of  the  gut  presents  either  the  appear- 
ance of  a  cylinder  or  of  an  inverted  cone,  with  the  mucous 
membrane  either  smooth  or  more  or  less  transversely  or 
obliquely  plicated.  At  the  apex  and  in  the  centre  of  the  cone 
or  cylinder  is  the  orifice  of  the  bowel.  "When  small  intestine 
bulges  into  the  peritoneal  pouch  on  the  anterior  aspect  of  the 
prolapse,  it  is  apt  to  cause  the  orifice  at  the  apex  of  the  pro- 
trusion to  be  directed  somewhat  backwards.  The  sides  of  the 
prolapse  slope  upwards  and  become  continuous  with  the  skin 
surrounding  the  dilated  and  stretched  anal  orifice.  The 
appearances  of  the  mucous  membrane  vary  according  to  the 
acuteness  or  chronicity  of  the  case.  When  only  recently  pro- 
truded, it  may  be  florid  in  colour,  covered  with  mucus,  and 
prone  to  bleed ;  but  when  the  case  is  of  old  standing,  and 
especially  if  the  prolapse  remains  down,  the  membrane  be- 
comes pale  in  colour  and  more  or  less  indurated,  resembling 
skin,  or,  if  very  tough,  not  unlike  leather.  Patches  of  ulceration 
are  sometimes  present. 

Most  of  the  symptoms  strictly  attributable  to  prolapse 
of  the  rectum  arise  when  for  some  reason  the  bowel  cannot 
be  immediately  and  easil}^  returned  after  its  descent.  The 
constant  dragging  effect  of  the  prolapse,  and  the  constriction 


6i0  THE   RECTUM 

at  the  anus,  tend  each  to  produce  its  own  train  of  symptoms. 
Thus  the  anatomical  relation  of  the  urethra  and  the  bladder 
in  the  male  causes  this  part  to  be  pulled  upon  by  the  prolapse, 
so  that  pain  and  difficulty  in  micturition  may  result ;  and  in 
some  cases  retention  of  urine  is  caused.  The  dragging  upon 
the  rectal  nerves  may  also  induce  distressing  pain  in  the 
loins  and  down  the  thighs.  When  constriction  takes  place  at 
the  anal  orifice,  the  prolapse  becomes  strangulated  and  acute 
pain  immediately  follows,  with  congestion,  inflammation,  and 
possibly  sloughing  of  the  part.  In  exceptional  instances  the 
prolapse  completely  sloughs  off,  and  a  natural  cure  results. 

In  chronic  conditions  of  prolapse  there  are  apt  to  be 
frequent  attacks  of  bleeding,  while  constipation  alternates 
with  diarrhoea.  In  some  cases  there  is  fsecal  incontinence. 
The  straining  also,  which  is  sometimes  a  constant  and  aggra- 
vating symptom,  has  in  rare  instances  resulted  in  rupture 
of  the  bowel.  Such  an  exceptional  complication  is  recorded 
by  Masimoff.'  A  woman  aged  75  had  suffered  for  nine  years 
from  habitual  prolapse  of  the  rectum.  While  straining  during 
defecation  she  suddenly  felt  acute  pain,  followed  by  protrusion 
of  bowel  from  the  anus.  Quenu  ^  also  records  a  case  occurring 
in  a  feeble  old  woman  and  under  similar  circumstances. 
When  first  seen,  three  feet  of  intestine,  black  and  shrivelled, 
protruded  from  the  anus.  Laparotomy  was  performed,  the 
bowel  reduced,  and  an  attempt  made  to  suture  the  rent  in 
the  rectum,  but  without  success.     The  patient  succumbed. 

Treatment. — ^It  need  hardly  be  pointed  out  that,  inasmuch 
as  prolapse  of  the  bowel  is  in  the  majority  of  instances  a 
symptom,  the  cause  which  has  given  rise  to  it  needs  to  be 
rectified  in  the  first  place.  Assuming  therefore  that  the 
local  or  constitutional  exciting  or  predisposing  cause  has  been 
attended  to,  the  treatment  of  the  prolapse  may  next  be  con- 
sidered. 

In  children  the  simplest  method  of  treatment  for  slight 
cases  consists  in  first  placing  the  child  on  its  abdomen  across 
the  mother's  knees,  the  buttocks  raised,  and  the  thighs  flexed. 
The  prolapse  is  cleansed,  and  then  besmeared  with  some 
vaseline  ;  gentle  pressure  is  applied  to  the  apex  of  the  cone 

'  Annals  of  Sitrgcry,  1890,  vol.  xii.  p.  281. 

2  Medical  Press  and  Circular,  1888,  N.S.  vol.  xlv.  p.  141. 


PKOI.APSK  6'41 

or  cylinder  with  the  fingers  until  it  slips  up  within  the  anus. 
The  child  ehould  afterwards  be  kept  in  the  recumbent  position  ; 
a  pad  and  T-bandage  applied,  or  the  buttocks  held  close  to- 
gether by  strips  of  adhesive  plaster.  All  motions  should  be 
passed  while  the  child  lies  on  its  side  ;  and  in  order  to  exer- 
cise some  restraining  effect  against  he  return  of  the  prolapse, 
one  buttock  may  be  drawn  aside,  so  as  to  put  tension  on  the 
anal  orifice  while  defecation  takes  place. 

When  the  prolapse  shows  a  tendency  to  recur,  the 
patient  may  be  treated  with  some  form  of  astringent. 
Bryant '  advocates  the  free  application  of  nitrate  of  silver  as 
stick  to  the  whole  mucous  surface,  previously  wiped  with  lint 
and  subsequently  mopped.  Or,  as  recommended  by  Henry 
Smith,^  the  part  may  be  bathed  with  a  solution  of  sulphate  of 
iron,  one  grain  to  the  ounce  of  water.  Another  method  is  to 
use  astringent  injections  after  a  motion  and  after  the  bowel 
has  been  returned.  For  this  purpose  three  or  four  ounces  of 
water  containing  three  grains  of  tannic  acid  to  the  ounce  may 
be  used,  or  a  decoction  of  oak  bark  with  or  without  alum. 

As  further  adjuncts  towards  maintaining  the  bowel  in 
position,  some  form  of  rectal  pessary  may  be  used.  Logan 
employs  a  perforated  celluloid  tube,  three-eighths  of  an  inch  in 
external  diameter  and  four  inches  long.  Ball  advises  an  oval 
knob  of  vulcanite  with  a  very  slender  curved  shank,  to  which 
a  piece  of  twine  is  attached. 

Should  the  case  still  resist  such  simple  measures,  the 
mucous  membrane  of  the  prolapse  must  be  painted  over  with 
strong  nitric  acid,  a  camel's-hair  brush  being  used  for  the 
purpose.  Chloroform  must  be  administered,  the  mucous 
membrane  dried,  and  care  taken  not  to  touch  the  skin  around 
the  anus  with  the  acid.  After  the  application  the  part  is 
oiled  and  returned,  and  the  rectum  stuffed  with  some  cotton 
wool.  The  straining  which  is  liable  to  follow  upon  the  child's 
recovering  consciousness  necessitates  the  application  of  a  pad 
and  bandage,  and  the  strapping  of  the  buttocks  together. 
Allingham  ^  orders  a  mixture  of  aromatic  confection  with  a 
drop   or  two  of   tincture  of  opium,  in  order  to  confine  the 

'  Practice  of  Surgery,  3rd  edit.  vol.  i.  p.  715. 

-  Holmes's  System  of  Surgery,  3rd  edit.  vol.  ii.  p.  84.5. 

^  Diseases  of  the  Rectum,,  -itli  edit,  p-  105.. 

T  T 


642  THE   RECTUM 

bowels  for  four  days.  A  teaspoonful  of  castor  oil  is  then 
given,  the  strapping  pad  and  bandage  removed,  and  the  first 
motion  brings  away  the  woollen  stuffing.  A  single  applica- 
tion of  the  acid  is  usually  sufficient,  but  occasionally  a  second 
and  even  a  third  may  be  required. 

In  any  case  where  there  is  difficulty  in  reducing  the  pro- 
lapse in  children,  the  result  of  crying  and  straining  on  the 
part  of  the  patient,  chloroform  should  be  administered,  so  as 
to  avoid  injuring  the  bowel  by  any  undue  force. 


CHAPTEE  LXXVIII 


PROLAPSE  (continued),     treatment  in  adults,     intussus- 
ception.     RECTAL   HERNIA.      RECTOCELE 

In  adults  the  prolapse,  if  of  any  magnitude  or  chronicity,  is 
seldom  amenable  to  such  simple  measures  as  in  the  case 
of  children.  In  recent  cases,  however,  and  in  such  as  consist 
of  the  prolapse  of  mucous  membrane  only,  astringent  in- 
jections should  be  tried,  or  the  systematic  employment  of 
cold-water  enemata,  before  attempting  any  more  radical 
means. 

When  operation  becomes  necessary,  several  methods  are 
at  present  in  vogue,  all  of  which  have  been  practised  with 
success  ;  and  although  their  respective  merits  are  regarded 
with  very  variable  degrees  of  approval  among  surgeons,  they 
at  least  deserve  recognition  both  for  the  ingenuity  which 
characterises  some  and  the  good  results  that  have  followed 
in  all. 

Among  the  more  conservative  measures  are  the  use  of  the 
clamp  and  the  cautery  :  the  application  of  the  cautery  alone ; 
the  excision  of  an  elliptical  portion  of  the  mucous  membrane ; 
or  this  in  conjunction  with  the  skin,  as  practised  by  Eoberts. 

Severer  operations  consist  in  amputation  of  the  part  by 
methods  proposed  respectively  by  (A)  Mikuhcz,  by  (B)  Treves, 
and  by  (C)  Kleberg  :  in  elevation  and  fixation  of  the  prolapse, 
either  (A)  by  way  of  the  sacrum,  as  proposed  by  Verneuil,  or 
(B)  by  transfixion  above  Poupart's  ligament,  as  carried  out 
by  McLeod,  or  (C)  by  preliminary  laparotomy,  as  practised  by 


PROLAPSE— TREATMENT  643 

Berg.  Lastly,  a  method  for  narrowing  the  canal  has  been 
proposed  by  Lange,  which,  following  the  nomenclature  used  in 
other  parts  of  the  intestine,  might  be  called  '  proctorrhaphy.' 

By  clamp  and  cautery. — By  this  method  folds  of  mucous 
membrane  are  clamped  in  a  similar  way  to  that  in  which 
haemorrhoids  are  secured.  The  clamped  portion  is  removed 
either  by  the  thermo-cautere  or  heated  irons ;  in  each  case 
the  heat  should  not  be  beyond  that  which  produces  a  dull  red 
colour.  The  amount  to  be  removed  depends  upon  the  nature 
and  extent  of  the  prolapse.  Several  portions  may  need  to  be 
clamped,  and  where  the  anal  orifice  is  very  patulous  a  piece 
of  skin  may  also  be  included.  Henry  Smith  '  advocates  and 
practises  this  method  in  preference  to  others. 

By  cautery. — This  method  of  treatment  was  suggested  by 
van  Buren  of  New  York,  and  was  advocated  and  practised  by 
the  late  William  Allingham,^  who  thus  describes  the  opera- 
tion : 

'  The  patient  is  put  under  the  influence  of  ether,  and  if 
the  part  be  not  down  it  can  be  readily  drawn  fully  out  of  the 
anus  by  the  vulsellum.  I  then,  having  the  intestine  held 
firmly  out,  with  the  iron  cautery  at  a  dull  red  heat,  make 
four  or  more  longitudinal  stripes  from  the  base  to  the  apex  of 
the  protruded  intestine.  I  take  care  not  to  make  cauterisa- 
tion so  deep  towards  the  apex  as  at  the  base,  because  near 
the  apex  the  peritoneum  may  be  close  beneath  the  intestine, 
while  a  deep  burn  near  the  base  is  not  so  dangerous.  I  take 
care  to  avoid  the  large  veins  which  can  be  seen  on  the  surface 
of  the  bowel.  If  the  procidentia  be  very  large  I  make  even 
six  stripes.  I  then  oil  and  return  the  intestine  within  the 
anus  ;  having  done  this  I  partially  divide  the  sphincters  on 
both  sides  of  the  anus  with  a  sawing  motion  of  the  hot  iron, 
and  then  insert  a  small  portion  of  oiled  wool.' 

The  patient  is  kept  in  the  recumbent  position  for  a  month 
or  six  weeks,  and  the  motions  are  passed  while  the  patient  is 
lying  down. 

The  principle  of  the  treatment  is  to  lessen  the  calibre  of 
the  canal  by  the  cicatricial  contraction  which  follows  upon 
the  healing  of  the  ulcers  after  the  separation  of  the  sloughs ; 

•  Lcmcct,  1893,  vol.  i.  p.  459. 

-  Diseases  of  tJie  Rectum,  4tli  edit  j).  IGD. 

X   T  2 


644  THE   RECTUM 

and  the  formation  of  inflammatory  adhesions  between  the 
mucous  and  the  muscular  tunics  of  the  rectum. 

This  operation  can  also  be  performed  after  the  prolapse  is 
reduced.  In  such  cases  a  wire  or  other  suitable  speculum  is 
used,  which  will  admit  of  the  iron  or  cautery  being  introduced 
and  the  mucous  membrane  seared  as  above. 

By  elliptical  excisions. — This  method  has  for  its  object  a 
similar  result  to  that  attained  by  the  use  of  the  cautery. 
Elliptical  portions  of  the  mucous  membrane  are  excised  in  the 
longitudinal  axis  of  the  bowel.  Their  removal  necessitates  the 
healing  of  the  raw  gaps  by  cicatricial  tissue  which  results  in 
a  narrowing  of  the  canal.  When,  however,  there  is  much 
dilatation  of  the  anus,  something  further  is  needed  in  the  way 
of  narrowing  this  orifice.  The  operation  devised  by  Eoberts 
appears  best  suited  for  the  purpose. 

Roberts's  oideration} — The  operation  is  thus  described  by  its 
author  in  narrating  a  case  successfully  treated  by  it. 

'  The  patient  was  put  in  the  lithotomy  position  and  the 
protruded  rectum  fully  reduced.  I  then  made  a  small  incision 
in  the  median  line  of  the  perineum,  near  the  point  of  the 
coccyx  ;  into  this  I  inserted  my  finger  and  broke  up  the  cellular 
connections  posterior  to  the  rectum,  in  a  manner  similar  to 
that  adopted  in  excision  of  the  lower  end  of  the  rectum  for 
carcinoma.  A  knife  was  then  introduced  into  the  dilated 
anus  at  a  point  half  an  inch  to  the  right  of  the  median  line, 
and  a  deep  incision  carried  obliquely  backward  so  that  it 
divided  the  anal  sphincter  and  skin  from  the  aperture  of  the 
bowel  to  the  original  incision  made  at  the  end  of  the  coccyx. 
The  knife  was  then  introduced  into  the  anus  upon  the  left 
side  of  the  median  line,  and  a  similar  incision  carried  back  to 
the  original  wound  in  the  perineum.  These  oblique  incisions 
included  between  them  a  triangular  portion  of  tissue  consist- 
ing of  skin,  subcutaneous  cellular  tissue,  and  an  inch  of 
the  sphincter  muscle.  The  base  of  the  triangle  was  at  the 
margin  of  the  anus ;  its  apex  was  at  the  extremity  of  the 
coccyx.  About  one  inch  of  the  sphincter  muscle  was  thus 
excised  by  the  two  incisions.  With  scissors  I  then  cut  out  of 
the  posterior   wall   of  the   rectum  a   long   triangular   piece 

*  American  Joiirnal  of  the  Medical  Sciences,  1893,  N.S.  vol.  cv.  p.  541. 


PROL  A  rSE— OPERATION 


645 


embracing  the  entire  thickness  of  the  wall,  which,  in  the  first 
step  of  the  operation,  had  been  separated  from  its  pelvic 
connections.  The  apex  of  this  V-shaped  section  of  the  wall  oi 
the  rectum  was  situated  about  three  inches  up  the  gut,  while 
its  base  corresponded  with  the  inch  of  the  sphincter  muscle  of 
the  anus,  which  had  been  included  between  the  incisions 
previously  described.'  (See  fig.  105.)  '  After  haemorrhage  had 
been  controlled  by  catgut  ligatures,  chromicised  catgut  sutures 


tvatROsnY  fe. 


'■gfS/TUBEROsrrv 


Fig.  105 — Eobebts's  Operation  for  Prolapse  of  the  Eectum 


were  used  to  bring  the  divided  wall  of  the  rectum  together. 
The  first  suture  was  introduced  at  the  apex  of  the  rectal 
wound ;  that  is,  three  inches  above  the  anus,  and  was  tied 
with  the  knot  within  the  bowel.  Successive  sutures  were 
similarly  inserted  and  tied  at  intervals  of  about  one-third  of 
an  inch.  The  last  intrarectal  suture  was  placed  just  inside 
the  margin  of  the  anus.  The  sutures  were  all  tied  with  the 
knots  upon  the  mucous  surface  of  the  bowel.  .  .  .  The  ends  of 
the  divided  anal  sphincter,  which  were  left  by  the  excision  of 
one  inch  of  that  muscle,  were  then  brought  together  by  two 
catgut  sutures,  and  one  wire  suture,  which  was  shotted.  .  .  . 
A  rubber  drainage  tube  was  then  introduced  into  the  space 
between  the  rectum  and  the  sacrum,  and  the  wound  leading 
backward  from  the  anus  to  the  coccyx  was  closed  by  numerous 
shotted  wire  sutures  carried  deeply  through  the  structures  by 
means  of  a  strong  curved  perineum  needle.' 

In  place  of  using  gut  for  sutures,  Eoberts  now  advocates 
sterilised  silk ;  and  also  advises  that  the  bowels  be  kept  well 
confined  for  a  few  days  by  opium. 


646 


THE   RECTUM 


Two  cases  successfully  treated  by  this  method  are  reported 
by  Kammerer/  and  one  by  Bell.^ 

By  amputation. — (A)  Method  of  Mikulicz.^ — The  patient  is 
placed  in  the  lithotomy  position,  and  the  prolapsed  bowel  pro- 
perly cleansed  and  disinfected.  The  operator  then  inserts  the 
index  finger  of  the  left  hand  into  the  prolapse,  and  cuts  through 


Fig.  106. — Mikulicz's  Operation  fob  Pbolapse  of  the  Eectum.     (Bogdanik) 

with  a  knif'3  the  external  intestinal  tube  for  about  two  centi- 
metres parallel  to  the  anal  margin,  and  one  to  two  centimetres 
distant  from  it.  Care  is  then  taken  to  note  that  nothing  exists 
between  the  inner  and  outer  tube.  This  being  observed  to  be 
empty,  a  stitch  is  then  passed  so  as  to  unite  both  tubes ;  a 
reef-knot  is  tied,  one  end  left  short  and  free,  while  the  other 

•  Annals  of  Surgery,  1894,  vol.  xix.  p.  240. 
2  Ibid.  1891,  vol.  xiii.  p.  333. 

^  Bogdanik,  Archiv  fiir  klin.  Chir.  1894,  vol.  xlviii.  p.  847  ;  also  Volkmann 
Berliner  klin.  Wochenschrift,  1889,  No.  46,  p.  994. 


rUOLAPSE— OrERATlON  617 

Is  used  as  a  continiiotis  quilted  suture  through  the  rest  of  the 
circumference  of  the  boweL  As  the  stitching  proceeds  and 
the  needle  is  passed  through  the  two  tubes,  the  external  tube 
is  cut,  so  that  by  the  time  the  prolapse  has  been  stitched  com- 
pletely round,  the  external  tube  has  been  entirely  severed. 
The  internal  tube  is  now  cut  through,  and  the  cut  edges  of 
the  mucous  membrane  united  by  a  continuous  suture  all 
round.  The  stump  is  prevented  from  slipping  within  the  anus 
by  being  held  with  forceps.  There  are  no  vessels  to  tie,  because 
the  process  of  stitching  has  effectually  secured  them  before 
the  two  tubes  are  severed.  The  stump  is  finally  cleaned  and 
allowed  to  slip  back  within  the  anus. 

(B)  Method  of  Treves.^ — The  following  is  an  abstract  of  the 
method  as  practised  by  its  author  in  a  severe  case  of  prolapse, 
the  protrusion  measuring  five  inches  in  length,  and  ten  and  a 
half  inches  in  circumference  at  its  base. 

The  patient  was  placed  in  the  lithotomy  position,  and  the 
prolapse  drawn  down  to  its  full  extent.  The  mucous  mem- 
brane forming  the  outer  wall  of  the  prolapse  was  now  prepared 
for  separation  around  the  entire  base  of  the  cone,  the  knife 
traversing  the  skin  close  to  its  line  of  junction  with  the  mem- 
brane. The  tunic  was  then  separated  from  the  prolapse  by 
means  of  scissors  aided  by  traction,  and  was  everted  down  to  the 
apex  of  the  cone,  exposing  the  protrusion,  now  quite  bared  of 
mucous  membrane.  It  was  noted  that  there  was  a  laxity  of 
the  wall  at  the  base  of  the  cone  in  front,  but  no  small  intestine 
appeared  to  be  present,  the  raised  position  of  the  pelvis 
apparently  effected  gravitation  of  the  bowel  towards  the 
abdominal  cavity.  The  prolapse  was  then  cut  across  at  the 
level  of  the  anus  ;  that  is,  at  the  base  of  the  cone.  The 
anterior  wall  was  first  divided  and  the  peritoneum  opened,  the 
opening  being  plugged  with  a  sponge.  The  rest  of  the  pro- 
lapse was  then  rapidly  severed  with  scissors,  the  cut  end  of 
the  bowel,  muscular  and  mucous  coats  together,  being  seized 
with  pressure  forceps  as  each  inch  or  so  was  severed  ;  this 
allowed  of  the  immediate  arrest  of  all  bleeding,  and  also  pre- 
vented the  mucous  membrane  from  being  withdrawn  into  the 
rectum,  and  held  the  cut  end  of  the  bowel  in  position.  The 
small  plug  of  sponge  having  been  removed,  the  peritoneal 

'  Laiicet  1890  vol.  i.  p.  397. 


648  THE   RECTUM 

wound  was  closed  by  means  of  some  six  or  seven  points  of  the 
finest  chromicised  catgut.  The  divided  ends  of  the  bowel  were 
next  attached  to  the  margin  of  the  anus  by  sutures  of  silkworm 
gut  involving  the  whole  thickness  of  the  rectal  wall.  As  the 
pressure  forceps  were  removed  to  prepare  each  segment  of 
the  divided  rectum  for  fixing  in  place,  any  bleeding  point  was 
ligatured. 

(C)  Method  of  Kleberg . — The  essential  feature  of  this  method 
of  amputating  is  the  use  of  an  elastic  ligature,  by  which  means 
no  haemorrhage  occurs  and  no  prolapse  of  small  intestine  is 
possible.  The  mode  of  operating  is  thus  translated  from  the 
original  ^  by  Kelsey,^  from  a  case  in  which  it  was  performed. 
'  After  the  patient  had  pressed  down  the  gut  as  far  as  he  could, 
he  was  placed  in  the  lateral  position,  on  the  operating  table, 
with  the  pelvis  raised  and  the  shoulders  turned  downwards. 
After  the  administration  of  the  anaesthetic,  an  assistant,  sur- 
rounded with  all  the  fingers  the  prolapsus  from  above,  the 
points  of  the  fingers  being  directed  towards  the  free  end  of  the 
prolapsus,  and  pressed  as  hard  as  possible  into  the  gut  at  a 
point  perhaps  half  an  inch  below  the  supposed  sphincter. 
Immediately  in  front  of  the  ends  of  the  assistant's  fingers  I 
then  placed  a  good,  fresh,  unfenestrated  drainage  tube  of 
rubber,  a  line  and  a  half  in  diameter,  around  the  prolap- 
sus, and  drew  it  only  as  tight  as  seemed  necessary  to  stop  the 
circulation.  The  elastic  ligature  was  brought  to  the  necessary 
tension  by  means  of  an  easily  untied  slip-knot  of  silk  thrown 
under  it. 

'  The  assistant  now  had  both  hands  free.  ...  A  few  lines 
beneath  the  ligature  I  now  made  a  longitudinal  incision  two 
inches  long  through  the  prolapsed  gut,  and  in  this  way  opened 
the  sac  formed  by  the  drawing  down  of  the  peritoneum. 
Then  I  seized  the  elastic  ligature  with  the  forceps  and  fixed  jt 
firmly.  It  was  thus  an  easy  matter  to  push  back  into  the 
peritoneal  cavity  a  protruding  loop  of  intestine  without  the 
slightest  bleeding  taking  place  into  the  wound  or  any  air 
entering  the  peritoneal  cavity,  because  the  elastic  pressure 
follows  so  rapidly  all  the  movements,  that  no  opening  can  exist 
anywhere. 

'  Archiv  filr  klin.  Chir.  1879,  Bd.  xxiv.  p.  841. 
-  Diseases  of  the  Rcclwn,  1883,  p.  123. 


PROLAPSE— OPERATION  649 

*  After  I  had  convinced  myself  that  the  peritoneal  sac  was 
empty,  and  that  no  invagination  of  the  intestine  was  present, 
but,  on  the  other  hand,  only  that  part  of  the  gut  which  was 
to  be  removed  lay  in  front  of  the  ligature,  I  thrust  the  largest 
size  Luer's  pocket  trocar  through  the  prolapsus,  immediately 
below  the  elastic  ligature,  from  before  backwards,  and  passed 
through  the  canula  two  elastic  drainage  tubes  of  a  line  and  a 
half  in  diameter,  and,  after  removing  the  canula,  tied  them 
as  tightly  as  possible,  one  on  the  right  side,  the  other  on  the 
left.  These  knots  were  secured  against  slipping  by  means 
of  the  knot  of  silk.  The  first  provision  against  haemorrhage 
— the  elastic  ligature  applied  after  Esmarck's  plan — was  then 
removed,  and  the  prolapsus  cut  off  with  the  scissors  one  inch 
in  front  of  the  permanent  ligatures.  After  a  few  minutes' 
time,  during  which  I  kneaded  the  parts,  which  still  remained 
and  lay  above  the  ligatures,  thoroughly,  and  as  far  as  possible 
removed  the  fluids  from  them ;  I  covered  the  parts  around 
the  stump  with  cotton,  and  soaked  that  part  of  the  prolapse 
which  still  remained  above  the  ligature  with  a  solution  of 
chloride  of  zinc,  dried  it,  squeezed  the  soft  parts  once  more, 
thoroughly  applied  the  chloride  of  zinc  again,  and  then 
covered  the  whole  with  dry  cotton -batting,  giving  the  patient 
instructions  to  remove  this  as  soon  as  it  became  moist,  and 
to  replace  it  with  dry,  and  to  give  the  air  all  possible  access 
to  the  parts,' 

At  the  end  of  two  months  the  patient  is  reported  as  being 
perfectly  well.  The  prolapse  was  a  severe  one.  It  was  a  foot 
in  length  and  six  inches  in  diameter.  In  another  case 
operated  upon  the  result  was  fatal,  but  it  is  noted  that  the 
patient  was  in  a  very  bad  state  of  health. 

By  elevation  and  fixation.  (A)  Verneuil's  metJiod  byway  of 
the  sacrum. — The  object  of  this  operation  is  to  fix  the  prolapse 
through  an  opening  made  in  the  coccygeal  region,  so  that  the 
bowel  thus  secured  cannot  descend. 

The  operation  as  translated  by  Fowler  '  is  thus  performed. 
'  After  reposition  of  the  prolapsed  portion,  with  the  patient  in 
the  lithotomy  position,  two  incisions  from  four  to  five  centi- 
metres in  length  are  made  at  right  angles  to  the  long  axis 
of  the  anus,  from  the  opening  of  the  latter  in  an  outward 

'  Annals  of  Surgery,  1891,  vol.  xiii.  p.  218. 


650  THE   RECTUM 

direction.     From  the  points  where  these  incisions  terminate, 
two  other  incisions  pass  to  meet  each  other  at  the  point  of 
the  coccyx,  thus   including  an  equilateral   triangle   with  its 
base  placed  anteriorly.     This  triangular  flap  is  loosened  from 
behind  forward,  and  left  temporarily  attached  to  the  tissues 
surrounding  the  anus,  comprehending  in  its   thickness  the 
skin,  the  subcutaneous  cellular  tissue,  together  with  the  fibres 
of  the  external  sphincter.     With  this  flap  strongly  retracted 
by   means    of  blunt   retractors,    the    posterior   wall   of    the 
rectum  is  loosened  for  a  breadth  of  from  five  to  six  centi- 
metres and  to  a  height  corresponding  to  the  distance  from  the 
anus  to  the  tip  of  the  coccyx.     Four  threads  are  now  passed 
transversely  through  the  posterior  rectal  wall,  parallel  with  each 
other,  and  not  including  the  rectal  mucous  membrane.     The 
upper  one  of  these  sutures  is  placed  at  a  point  in  close  relation 
to  the  point  of  the  coccyx,  while  the  lower  one  is  removed  about 
fifteen   millimetres  from  the  anus.     By  means  of   a   needle 
with  an  eye  at  the  point,  which  is  passed  through  the  skin 
from  without,  the  threads  are  drawn  through  the  points  of 
emergence  of  their  respective  ends,  being  situated  at  about 
four  centimetres  from  the  median  lines  at  either  side.     The 
upper   suture   should  be   on   a   level   with    the   articulation 
between  the  first  bone  of  the  coccyx  and  the  sacrum,  and  the 
lower  at   the  point   of  the  coccyx;  the  intervening  sutures 
are   placed    about    equidistant    between.      These    are    now 
secured  upon  one  side  in  such  a  manner  that  the  first  and 
second,  and  the  third  and  fourth,  are  tied  together  ;  rolls  of 
iodoform  gauze  being  placed  beneath  the  loops  to  prevent  the 
latter  from  being  buried  with  the  skin,  strong  traction  upon 
these  secures  the  rectum  in  its  new  position,  and  the  other 
ends  of  the  thread  are  similarly  secured.     The  triangular- 
shaped  flap  is  now  removed,  the  muco-cutaneous  anal  margin 
being   preserved,  and   after   inserting   a  drainage  tube,  the 
wound  is  closed  by  sutures.' 

This  description  of  the  operation  differs  essentially  in  one 
particular  from  the  account  I  found  of  it.^  It  was  there 
stated  that  the  triangular  flap  is  not  removed,  but  replaced 
and  sutured.  Further,  I  translate  the  initial  steps  of  the 
operation  thus :  A  calculation  is  first  made  regarding  the  dilated 

•  Gazette  Ilcbdom.  cle  Med.  ct  de  Chir  1889,  vol.  xxvi.'  p.  812. 


TROLAPSE— OPERATION  651 

anus,  as  to  the  extent  of  the  boundary  necessary  to  prockice  a 
normal-sized  aperture.  From  pomts  equidistant  from  the 
median  hne  in  front,  and  where  it  is  beheved  the  remaining 
anterior  part  of  the  anal  circumference  contains  a  sufficient 
margin  when  united  to  form  a  normal  orifice,  incisions  are 
carried  horizontally  outwards  for  three  centimetres.  This 
appears  to  me  more  comprehensible  than  making  'two  in- 
cisions at  right  angles  to  the  anus.' 

The  narrowing  of  the  anus  is  effected  by  uniting  the 
margins  at  the  two  points  at  which  the  lateral  incisions  were 
carried  out. 

(B)  K.  McLeod's  method^  hy  transfixion  above  Poiqjarfs 
ligament. — The  essential  feature  of  this  operation  is  that  the 
prolapse  is  dealt  with  from  the  abdomen.  It  was  successfully 
practised  by  McLeod  in  a  case  thus  : 

'  The  left  hand  is  passed  into  the  bowel  and  the  fingers 
are  made  prominent  above  Poupart's  ligament.  A  long  steel 
acupressure  needle  is  passed  through  the  abdominal  parietes 
into  the  cavity  of  the  gut,  guided  across  its  interior  by  the 
fingers,  and  passed  outwards  until  it  emerges  about  three 
inches  from  the  point  of  entrance.  The  needle  should  be 
parallel  to  and  one  inch  above  Poupart's  ligament.  Another 
needle  is  passed  in  the  same  way  three  inches  above  the  first, 
and  external  to  it  so  as  to  secure  the  intestine  in  an  oblique 
position  from  below  upwards.  The  upper  end  of  the  rectum 
(or  it  may  be  the  lower  end  of  the  sigmoid  flexure)  is  thus 
temporarily  fixed  in  the  desired  position ;  the  hand  is  then 
withdrawn.  The  next  step  is  to  make  an  incision,  three 
inches  long  between  the  needles  and  at  right  angles  to  them, 
in  the  longitudinal  axis  of  the  intestine,  as  near  as  possible  to 
the  middle  line  of  the  attached  portion.  The  layers  are  to 
be  divided  separately  until  the  peritoneum  is  reached ;  the 
membrane  will  usually  bulge  out.  The  left  hand  is  now 
reintroduced  into  the  bowel,  and,  guided  by  the  fingers,  two 
series  of  loops  of  silk  thread  are  inserted,  four  on  each  side, 
at  a  distance  of  about  an  inch  apart,  so  as  to  attach  the 
serous  and  muscular  coats  of  the  intestine  to  the  abdominal 
wall.  A  series  of  these  loops,  also  penetrating  the  two  outer 
walls  of  the  intestine,  are  placed  between  successive  pairs  of 

'  Lancet,  1890,  vol.  ii.  p.  205. 


652  THE    RECTUM 

these  rows,  in  order  to  bring  the  lips  of  the  wound  together, 
and  between  them  smaller  horsehair  stitches  of  adaptation 
are  inserted.' 

The  patient  upon  whom  the  operation  was  performed 
made  a  good  recovery.  The  steel  pins  were  removed  in 
twenty-four  hours.,  and  the  horsehair  stitches  taken  out  on 
the  tenth  day. 

(C)  By  preliminary  laparotomy. — As  distinguished  from 
McLeod's  operation,  this  method  consists  in  first  opening 
the  abdomen  and  then  draiving  up  the  prolapsed  bowel,  and 
not  pushing  it  up  as  just  described. 

Berg  '  mentions  three  severe  cases  where  he  operated  by 
an  abdominal  incision.  The  abdomen  was  opened  in  the 
inguinal  region,  as  for  making  a  sigmoid  anus.  The  prolapse 
was  reduced,  and  the  sigmoid  flexure  and  upper  part  of  the 
rectum  drawn  up  and  secured  in  this  position  by  passing 
silk  sutures  through  the  whole  thickness  of  the  meso-rectum 
and  the  parietal  peritoneum. 

The  three  operations  just  described,  consisting  in  each 
case  of  the  reduction  of  the  prolapse  and  fixation  of  the  bowel 
above  by  suturing,  constitute  the  operations  known  as  recto- 
pexy or  proctopexy  when  the  rectum  is  secured,  and  colopexy 
when  the  colon  is  stitched  to  the  parietes. 

Lange's  method.^ — This  mode  of  operating  differs  from  those 
previously  described  in  that  it  seeks  to  cure  the  prolapse  by 
narrowing  longitudinally  the  calibre  of  the  canal.  The 
operation  is  thus  performed.  The  patient  is  placed  in  the 
knee-chest  position,  and  an  incision  made  from  the  lower  part 
of  the  sacrum  down  to  the  anus  until  the  posterior  part  of  the 
rectum  is  reached  ;  the  coccyx  is  then  removed.  The  rectal 
canal  is  narrowed  by  the  introduction  of  '  buried  etage  sutures 
of  iodoform  catgut,'  which  do  not  perforate  the  entire  thick- 
ness of  the  bowel.  The  first  row  are  inserted  near  the  middle 
line,  and  form  a  fold  in  the  posterior  wall,  which  protrudes 
into  the  bowel.  The  more  lateral  portions  of  the  gut  are  then 
brought  into  apposition  by  a  second  row  of  sutures.  Lastly, 
the  cut  edges  of  the  levator  ani  and  external  sphincter  are 


'  Annals  of  Surgery,  1893,  vol.  xvii.  p.  373. 
2  Ibid.  1887,  vol.  v.  p.  4i»7. 


INTUSSUSCEPTION  663 

united.     The  cavity  is  filled  with  iodoform    gauze,   and  the 
flaps  of  integument  united  with  sutures. 

The  case  successfully  treated  by  the  author  was  a  severe 
one.  The  prolapse  was  six  inches  in  length  :  had  existed  for 
twenty  years  :  and  had  resisted  repeated  treatment  by  cautery 
and  by  excision  of  mucous  membrane. 

Intussusception. —  Many  cases  of  prolapse  are  preceded  by 
intussusception  ;  that  is  to  say,  the  upper  part  of  the  rectum 
becomes  invaginated  into  the  lower,  and  the  intussusceptum 
continuing  to  descend,  eventually  presents  at  and  projects 
from  the  anus,  producing  in  the  most  extreme  cases  a  typical 
example  of  procidentia  recti.  The  most  distinguishing  feature 
of  an  intussusception  is  the  sulcus  which  exists  at  the  base 
of  the  prolapse.  When  the  finger  examines  or  traces  up- 
wards the  mucous  surface  of  the  outer  tube,  it  is  felt  to  pass 
between  two  layers  of  mucous  lining  until  it  is  checked  by 
the  reflection  of  the  mucous  membrane  at  the  neck  of  the 
intussusception. 

The  symptoms  of  an  intussusception  which  has  descended 
sufficiently  low  to  project  from  the  anus  are  practically  those 
of  prolapse  just  described.  But  when  an  intussusception 
exists  purely  within  the  rectum,  it  is  liable  to  be  overlooked 
or  mistaken  for  some  other  condition.  The  following  case, 
reported  by  Cripps,  illustrates  the  symptoms  which  may  be 
present. 

Case  CXIII. — Intussusception  of  the  rectum. 

The  patient,  a  girl,  was  admitted  into  St.  Bartholomew's  Hospital 
with  the  complaint  that  for  miore  than  two  years  she  had  passed  blood 
and  a  certain  amount  of  slime  daily.  "Whilst  in  the  hospital  the  bowels 
acted  several  times  a  day,  about  a  teaspoonful  of  blood  passing  with  each 
motion.  She  generally  strained  a  good  deal,  but  had  never  noticed  any 
protrusion.  She  had  but  little  pain  in  the  bowels  or  about  the  anus. 
She  was  very  weak  and  anaemic  from  continual  loss  of  blood.  After  a 
purge  and  a  soap-and-water  injection,  the  parts  were  examined,  and 
appeared  normal  with  the  exception  of  a  weak  sphincter.  There  was  no 
sign  of  piles.  By  gently  drawing  on  the  parts  and  telling  the  girl  to 
strain,  a  small  quantity  of  mucous  membrane  was  everted,  when  by  a 
sudden  effort  about  three  inches  of  the  bowel  shot  out.  At  the  top  of 
some  of  the  protruded  rugae  could  be  seen  several  shallow  ulcers  about  an 
eighth  of  an  inch  in  diameter.  As  the  prolapsed  part  became  congested, 
blood  at  once  commenced  to  ooze  from  the  margin  of  two  or  three  of  the 
ulcers,  and  in  a  few  seconds  accumulated  in  sufficient  quantity  to  drip. 


654  THE   RECTUM 

The  case  was  eventually  cured  hj  the  use  of  the  Imear  cautery.    (Harrison 
Cripps,  '  Brit.  Mea.  Journ.'  1887,  vol.  i.  p.  448.) 

Rectal  hernia, — In  this  rare  form  of  hernia  the  small 
intestine  projects  through  the  anterior  wall  of  the  rectum, 
forming  for  itself  a  sac  out  of  the  recto-vesical  or  recto-vaginal 
pouch  of  the  peritoneum  and  the  expanded  tunics  of  the 
rectal  wall.  The'  following  example  of  this  rare  disease  is 
reported  by  Lowe. 

Case  CXIV.  —Rectal  hernia. 
A  woman  aged  45  years  developed  a  hernia  of  the  small  intestine 
through  the  wall  of  the  rectum,  as  the  result  of  constant  violent  straining 
efforts  in  lifting  her  invaUd  mother.  The  sphincter  ani  was  dilated  to 
an  extreme  degree,  and  there  appeared  to  be  an  aggravated  form  of  pro- 
cidentia recti.  Any  straining  effort  caused  the  sweUing  to  become  tense 
and  smooth,  but  relaxation  of  the  effort  caused  the  protrusion  to  partly 
recede,  and  the  surface  of  the  mucous  membrane  to  become  flaccid  and 
covered  with  rug^.  In  operating  with  the  object  of  removing  some  folds 
of  mucous  membrane,  a  hernial  sac  was  opened,  and  several  coils  of  small 
intestine  were  forced  out.  These  were  reduced  and  the  opening  closed. 
The  patient  recovered,  and  became  practically  cured.  (Lowe,  '  St.  Bar- 
tholomew's Hospital  Reports,'  1891,  vol.  xxA-ii.  p.  59.) 

Rectocele. — '  The  condition  is  one  due  to  an  injury  sus- 
tained in  childbirth  which  becomes  exaggerated  as  a  woman 
passes  the  menopause,  and  as  the  vagina  is  shortened  in  after 
life.'  This  condition,  which  consists  of  an  undue  bulging  of 
the  anterior  wall  of  the  rectum  through  the  posterior  wall 
of  the  vagina,  is  usually  discussed  more  fully  in  works  upon 
gynoecology  than  iu  those  upon  general  surgery.  Its  treat- 
ment consists  in  narrowing  the  posterior  vaginal  wall,  and  so 
lessening  the  flaccid  condition  which  has  most  to  do  with 
determming  the  rectal  protrusion.  For  a  full  discussion  of 
the  causes  and  treatment  of  this  condition  the  reader  may  be 
referred  to  a  paper  by  Emmet,^  from  which  the  above  quotation 
is  taken. 


CHAPTEE   LXXIX 

MALFORMATIONS 


In  1860  were  published  two  contributions  upon  the  subject  of 
rectal  abnormalities,  both  of  which  have  received  world-wide 

'  American  Journal  of  Ohslcirics,  1890,  vol.  xxiii.  p.  G7b. 


MA  LFOKMATIUNS— PATHoLOi;  Y  (Jo5 

recognition.  The  one  was  by  Bodenhamer  '  of  New  York,  and 
the  other  by  CurHng  -  of  London,  The  latter  discussed  the 
subject  from  the  basis  of  100  cases  collected  from  all 
sources,  both  home  and  foreign.  In  1882  Cripps  ^  followed 
with  another  series  of  100  cases,  collected  also  from  all  sources, 
and  forming  a  continuation  of  those  collected  by  Curling.  In 
1887  Jeannel'*  published  an  essay  dealing  exhaustively  with 
the  etiology  and  pathology  of  the  subject ;  and  in  1893 
Ernst  Anders  ^  contributed  what  may  be  considered  a  resume 
of  all  past  work,  including  references  to  Bodenhamer,  Curling, 
and  Cripps  up  to  the  date  of  publication.  Not  the  least  instruc- 
tive feature  of  this  excellent  paper  is  the  tabulated  account  of 
100  cases,  showing  the  nature  of  the  malformation,  the  opera- 
tion performed,  and  the  result. 

Facts  abstracted  from  these  various  contributions  will  be 
further  referred  to. 

Pathology. — The  various  congenital  malformations  met 
with  are  the  result  of  some  defect  in  the  normal  process  of 
development,  which  shows  itself  almost  exclusively  on  the 
side  of  deficiency.  For  a  proper  comprehension  therefore  of 
these  aberrations,  a  knowledge  is  required  of  the  stages  in 
the  development  not  only  of  the  rectum  and  anus,  but  also  of 
the  bladder,  urethra,  vagina,  and  uterus.  It  would,  however, 
involve  too  lengthy  a  discussion  of  the  subject  to  introduce 
this  embryological  aspect  of  it ;  but  it  may  be  briefly  indicated 
that  the  rtctum  and  anal  portions  of  the  bowel  develop 
separately,  and  only  become  continuous  by  the  later  dis- 
appearance of  the  septum  which  interposes  between  the  two 
cul-de-sacs  ;  and  that  at  an  early  period  of  fcetal  life,  the 
lower  end  of  the  rectum  and  the  genito-urinary  tract  con- 
stitute a  common  cavity,  which  later  becomes  divided  into  its 
normal  channels  by  the  growth  of  septa. 

Thus  it  is  easily  seen  how  numerous  must  be  the  cases 
of  malformation  of  the  part,  dependent  upon  more  or  less 
deficiency  in  the  development  of  the  various  constituents  which 

'   Treatise  on  Becfal  Malformations. 

■  Trans.  Med.-Chir.  Soc.  Land.  1860,  vol.  xliii.  p.  1871. 

^  St.  Bartholovieiu^s  Hospital  Reports,  1882,  vol.  xviii.  p.  65. 

*  Revue  de  Chintrgie,  1887,  vol.  vii.  p.  190. 

*  Archil- fiir  Idin.  Chir.  ISCS,  vol.  xlv.  p.  490. 


666 


THE   RECTUM 


Fig.  107.— Normal  Rectum 


Fig.  108.— Atresia  Ani 


Fig.  109.— Atresia    Ani  with    Partial 
Absesce  of  Rectum 


Fig.  110.— Atresia  Ani  with   Complete 
Absence  of  Rectum 


Pig.  111.— Atresia  Ani  with  Fistulous 
Communication  with  the  Bladder 


Fig.  112.— Atbfsia  Ani  with  Fistulous 

COMMUNICAIION   with  THE  URETHRA 


Fig.  113.— Atresia  Ani  with  Fistulous 
Communication  with  the  Vagina 


Fir.  114. — Atresia  Ani  with  Fistulous 
Communication  with  the  Exterior, 
either  in  front,  behind,  or  at  the 
side  cf  the  normal  position 


Fig.  115.— Anal   Cul-de-sac    with  Mem- 
branous Partition 
The  rectal  cial-de-sac  maj'  lie  to  one  sifle  o^ 
tlie  anal 


Fig.  116. — Anal  Cul-desac  with  absence 
OP  Rectum,  either  partial  or  complete 


Figs.  107-117.  -  Diagramjiatic  Eepresentation  of  Malformations 
OF  THE  Anus  and  Eectum 


MA  LF(  )l{MATrf  )NS  Bo? 

go  to  form  the  normal  state.  To  what  the  original  cessation 
of  growth  is  due  is  unknown.  The  cause,  whatever  it  is,  is  as 
likely  to  be  in  the  ovum  as  it  proceeds  from  the  ovary,  as  it  is 
to  be  the  result  of  any  one  of  the  innumerable  influences 
brought  to  bear  upon  it  in  the  process  of  development  within 
the  uterus. 

In  order  to  simplify  the  description  of  the  commoner  forms 
of  malformation  met  with,  and  to  present  them  in  a  more 
impressive  shape,  I  have  made  a  series  of  diagrams  which 
must,  however,  be  taken  as  indicating  general  types  rather 
than  exact  pictures  of  what  may  be  found  in  the  class  of 
cases  which  they  are  intended  to  illustrate. 

These  diagrams  may  therefore  be  taken  to  represent  the 
usual  classification  of  malformations  now  adopted. 

I.  The  simplest  malformation  is  that  of  atresia  of  the  anus 
(fig.  108).  The  rectum  is  fully  developed,  and  also  the  anal 
cul-de-sac,  but  the  orifice  of  the  anus  itself  is  occluded  by  a 
membrane. 

II.  In  addition  to  the  anal  occlusion,  there  is  also  absence 
of  the  anal  cul-de-sac  (fig.  109).  To  this  may  be  added  more 
or  less  deficiency  in  the  development  of  the  rectum,  amounting 
in  some  cases  to  complete  absence  (fig.  110). 

III.  There  is  neither  anus  nor  an  anal  cul-de-sac,  and  the 
rectum  terminates  by  a  fistula  of  variable  dimensions  as  to 
length  and  capacity,  opening  either  into  the  bladder  (fig.  Ill), 
or  into  the  urethra  (fig.  112),  or  into  the  vagina  (fig.  113),  or 
into  some  part  of  the  perineum,  scrotum,  or  buttocks  (fig.  114) 
by  one  or  more  openings. 

IV.  Both  rectal  and  anal  portions  of  the  canal  may  be 
perfectly  developed,  but  the  septum  which  separates  the 
two  remains  intact.  Several  varieties  of  this  may  exist.  If 
the  normal  axes  of  the  two  segments  are  maintained,  the 
septum  exists  as  a  transversely  disposed  membrane  between 
the  apex  of  the  one  and  the  termination  of  the  other.  But 
the  two  cul-de-sacs  may  occupy  a  position  of  lateral  apposition, 
the  rectal  lying  in  front,  behind,  or  on  one  side  of  the  anal 
(fig.  115). 

V.  The  anal  portion  may  be  perfectly  developed,  but 
there  may  exist  partial  or  complete  absence  of  the  rectum 
(fig.  IIG). 


6o8  THE    RECTUM 

To  these  five  classes  must  be  added  other  eases  of  in- 
frequent and  rare  occurrence  which  from  time  to  time  are 
recorded.  Such  for  instance  as  the  case  recorded  by  Croft,' 
where,  at  the  dissection  after  death,  a  scarcely  pervious  canal 
was  detected  by  which  the  rectum  terminated  in  the  uterus. 
Also  the  cases  of  Cruveillier  and  Morgan  quoted  by  Kelsey.^ 
In  the  case  reported  by  the  former,  a  fistulous  communication 
ran  from  the  rectum  subcutaneously  in  the  scrotal  rajjhe 
and  terminated  at  the  glans  penis.  While  in  two  cases 
reported  by  the  latter,  a  broad  thick  band  passed  in  the 
one  case  from  the  tip  of  the  coccyx  to  the  median  raphe 
of  the  scrotum ;  and  in  the  other,  from  the  median  ra2)Jte 
of  the  perineum  in  front  to  the  depression  between  the 
buttocks  posteriorly.  These,  however,  and  other  like  cases 
are  interesting,  but  too  rare  to  require  more  than  a  passing 
notice. 

When  an  interval  of  some  extent  exists  between  the  rectal 
cul-de-sac  and  the  anus  or  the  anal  cul-de-sac,  it  is  always 
probable  that  the  rectal  segment  is  completely  surrounded 
by  peritoneum.  This  fact  is  of  importance  in  considering 
the  question  of  operation,  and  will  be  referred  to  again. 

Symptoms. — In  those  cases  where  there  is  no  outlet  for  the 
meconium,  the  discovery  is  soon  made  by  the  mother  or  the 
nurse,  either  that  there  is  visibly  something  defective  with 
the  child's  anus,  or  that  while  the  parts  appear  normal  it 
passes  nothing,  refuses  to  take  nourishment,  and  probably 
■s'omits  what  it  does  take.  In  the  course  of  a  day  or  two 
the  abdomen  commences  to  swell,  and  the  child  appears 
to  be  ill. 

The  existence  of  fistulous  communication  with  any  part 
of  the  genito-urinary  system  soon  becomes  manifest  by  the 
passage  of  the  meconium  through  either  the  urethra  or  the 
vagina.  In  the  case  of  fistulse  elsewhere,  the  true  nature 
of  the  case  is  soon  detected.  To  what  extent  other  symptoms 
may  arise,  irrespective  of  the  abnormal  discharge,  will  depend 
upon  the  calibre  of  the  fistula.  Should  this  be  narrow  enough 
to  act  as  a  source  of  obstruction,  vomiting  and  abdominal 
distension  may  soon  appear.     On  the  other  hand,  should  the 

'  Trans.  Path.  Soc.  Loncl.  1868,  vol.  xix.  p.  291. 
''  Diseases  of  the  Eectwn,  p.  34. 


MALFORMATIONS  (m 

passage  be  free  enough,  little  trouble  need  be  anticipated 
BO  long  as  the  meconium  remains  thin  and  fluid.  As,  how- 
ever, the  meconium  becomes  more  truly  ffecal  and  the  faeces 
assume  a  solid  consistency,  urinary  troubles  rapidly  arise  in 
those  cases  where  the  communication  exists  between  the 
rectum  and  the  bladder  or  urethra. 

Diagnosis. — As  a  rule  very  little  difficulty  is  experienced  in 
detecting  the  general  nature  of  the  case,  although  the  exact 
form  of  malformation  present  may  not  be  so  easily  deter- 
mined. The  cases  likely  to  mislead  are  those  where  an  anal 
cul-de-sac  exists,  and  where  the  early  symptoms  are  not 
severe.  I  know  of  such  an  instance  where  it  was  mistakenly 
assumed  that  the  child's  indisposition  was  due  to  gastric 
disturbance,  and  the  mother  was  told  to  return  for  advice  if 
the  child  did  not  improve.  I  saw  it  two  days  after  this 
advice  was  given,  and  found  that  a  catheter  passed  into  the 
rectum  was  stopped  about  an  inch  and  a  half  from  the  anal 
orifice. 

The  simple  statement  that  the  child  has  not  passed 
meconium,  although  the  other  symptoms  may  be  slight,  and 
even  absent,  should  be  a  sufficient  indication  for  the  practi- 
tioner to  make  a  careful  and  systematie  examination  of  the 
rectum  either  with  the  finger  or  by  the  introduction  of  a 
catheter. 

In  many  of  these  cases  there  is  evidence  of  some  lack  of 
development  of  the  pelvis,  so  that  it  appears  small  when 
compared  with  other  parts  of  the  body ;  and  the  tuber  ischii 
are  observed  to  be  abnormally  close  together.  Such  defects, 
or  rather  deficiency  in  the  growth  of  the  pelvis,  indicate  a  hke 
deficiency  in  the  development  of  the  intrapelvic  viscera ;  hence, 
when  this  condition  is  at  all  marked,  it  may  be  taken  as  indicat- 
ing partial  or  complete  absence  of  the  rectum. 

The  cases  difficult  to  diagnose  are  those  where  the  rectal 
cul-de-sac  ends  at  some  distance  above  the  apex  of  the 
anal  cul-de-sac  or  the  occluded  anus.  In  these  it  is  not 
possible  to  feel  any  bulging  or  impulse  in  applying  the  fingers 
to  the  parts  below  when  the  child  cries,  or  when  pressure  is 
made  by  the  hand  upon  the  abdomen.  On  the  other  hand 
the  conveyance  of  such  impressions  is  significant  of  a  thin 
septum    between   the  contents   of  the  bowel  above  and  the 


BiO  THE   RECTUM 

exterior.     In  the   case   of  females   some  assistance  may  be 
obtained  by  digital  examination  of  the  vagina. 

Prognosis. — In  considering  the  futm'e  of  these  cases  it  is 
necessary  in  the  first  place  to  deal  with  them  independently 
of  treatment,  and  in  the  second,  with  the  prospects  held  out 
by  operation. 

It  need  hardly  be  said  that  httle  or  no  hope  exists  in  those 
cases  where  there  is  complete  obstruction.  Such  remarkable 
instances  as  those  recorded  respectively  by  Cripps  ^  and  by 
Mercier  ^  are  too  exceptional  to  admit  of  having  any  weight 
in  mitigating  the  usual  forecast  of  a  rapidly  fatal  result. 
In  the  former  case  the  child  lived  and  kept  quite  well  for 
thirty  days.  Three  or  four  times  every  day  she  vomited 
fgecal  matter.  In  the  latter  case,  a  weU-nourished  girl  aged 
13  years  evacuated  fsecal  matter  by  vomiting  every  fourth  or 
fifth  day. 

The  prognosis  in  regard  to  fistulous  communications  is 
not   so   hopelessly  bad  as  in  the  case  of  total  obstruction. 
Not  a  few  cases  are  on  record  where  patients  born  with  this 
type  of  malformation  have  lived  for  years.     Much  depends 
upon   the   situation  of  the  fistula,   and   the  readiness  with 
which  the  faeces  make  their  exit  through  it.     When  the  com- 
munication is  with  the  bladder  or  the  urethra,   cystitis  is 
sooner  or  later  set  up,  and  the  child  dies  of  this  or  of  obstruc- 
tion.    There  are  even  exceptions  to  this  rule,  and  a  remark- 
able case  reported  by  F.  Page  ^  illustrates  how  nature  can 
sometimes   overcome  these  difficulties.      Immediately   after 
birth,  urine  and  fseces  were  passed  by  the  urethra,  the  anus 
being  imperforate.     At  the  age  of  10  years  the  urethra  became 
blocked  with  hardened  faeces,  and  relief  was  obtained  by  an 
inciaion  into  it  immediately  in  front  of  the  scrotum.     The 
result  was  a  permanent  fistula,  through  which  the  patient 
continued  to  pass  urine  and  faeces.     He  was  in  the  habit  of 
taking  a  laxative  daily,  and  had  to  squeeze  the  faeces  through 
the,  fistula  with  his  fingers.     From  time  to  time  the  urethral 
fistula  became  blocked,  and  then  everything  was  passed  by  the 
meatus.     When  last  seen,  this  man  had  reached  the  age  of 

>  Trans.  Path.  Soc.  Lond.  1880,  vol.  xxxi.  p.  112. 
-  Cripps,  Diseases  of  the  Rectum,  p.  28. 
s  Brit.  Med.  Journ.  1888,  vol.  ii.  p.  875. 


MALFORxMATIONS  661 

54.  Kelsey  '  quotes  Gross  as  recording  the  case  of  a  man 
who  Kved  to  the  age  of  30,  and  also  cites  Bodenhamer  as 
giving  several  others  in  Nvhich  children  have  lived  three  or 
four  years.  The  same  author  refers  to  Rowan's  case,  where 
defecation  took  place  through  the  penis  for  two  months  with- 
out causing  any  signs  of  irritation,  though  the  child  was 
several  months  old. 

The  cases  in  which  prognosis  is  most  favourable  are  those 
where  the  communication  is  between  the  rectum  and  the 
vagina.  It  usually  happens  that  the  orifice  of  the  fistula  is 
situated  near  the  vaginal  entrance.  In  all  the  cases,  twelve 
in  number,  of  Cripps's  series  of  100,  the  opening  was  in 
the  posterior  wall,  just  behind  the  hymen.  If  the  orifice 
and  the  fistula  are  of  sufficient  size  to  allow  of  a  ready  escape 
of  the  fseces,  the  child  may  live  for  years  and  even  reach  old 
age,  with  nothing  more  to  complain  of  than  the  inconvenience 
associated  with  the  abnormal  fsecal  outlet.  In  a  case  recorded 
by  Byron, '^  the  foecea  were  completely  retained  by  a  sphincter 
in  the  vagina  imtil  the  rectum  became  filled  with  fsecal 
material.  Cooper  ^  quotes  two  cases,  one  by  Abel  of  a  woman 
aged  20,  in  whom  the  faeces  could  be  held  and  periodically 
evacuated  without  trouble ;  and  another,  by  Ricord,  of  a 
woman  aged  22,  who  could  similarly  retain  her  faeces  and 
defecate  without  trouble.  In  the  latter  case  the  woman  had 
been  married  for  three  years,  and  the  malformation  had  not 
been  discovered  by  her  husband.  Ball  *  records  the  case  of  a 
woman  who  was  the  mother  of  six  children.  The  anus 
opened  into  the  lower  portion  of  the  vagina,  and  was  so  far 
provided  with  a  sphincter  that  the  top  of  the  finger  when 
introduced  into  the  rectum  was  tightly  grasped.  She  never 
suffered  from  the  slightest  inconvenience. 

In  most  cases  where  symptoms  of  obstruction  set  in,  death 
results  from  exhaustion  ;  there  is,  however,  the  possibility  of 
the  distended  bowel  rupturing.  In  a  case  recorded  by  Fuller,''' 
the  abdomen  on  the  fifth  day  after  birth  was  enormously  dis- 
tended, and  tympanitic.     After  death  it  was  found  that  the 

^  Diseases  of  the  Rectum,  p.  36. 

*  New  York  Med.  Joiirn.  1894,  vol.  lix.  p.  247. 

^  Diseases  of  the  Rectum,  p.  54.  *  Ibid,  p.  44. 

*  Lancet,  1894,  vol  i.  p.  1499. 


662  THE   RECTUM 

rectum  above  the  septum  presented  about  its  centre  a  hole 
large  enough  to  admit  three  fingers.  The  edges  of  the  ori- 
fice were  sloughy,  suggesting  a  rupture  some  time  before 
death.  Meconium  was  found  extravasated  into  the  peritoneal 
cavity. 

Prognosis  in  regard  to  operation. — It  naturally  follows  that 
the  simpler  the  operation  requisite  to  deal  efficiently  with  the 
malformation,  the  more  likely  is  treatment  to  be  successful. 
Thus  it  is  found  that  the  best  results  follow  the  treatment  of 
vaginal  fistula,  while  the  worst  are  those  in  which  an  artificial 
anus  is  made  either  in  the  inguinal  region  or  in  the  loin.  In 
neither  of  these  classes  of  case,  however,  is  it  right  to  attribute 
success  or  failure  altogether  to  the  operation  ;  for  in  the 
one  class  the  type  of  the  malformation  is  the  least  serious, 
while  in  the  other  it  ranks  among  the  most  fatal.  The  pro- 
spect of  success  or  failure  in  regard  to  the  nature  of  the 
operation  performed  is  best  seen  by  a  reference  to  the  tables 
compiled  respectively  by  Cripps  and  by  Anders. 

Results  of  operations  in  Crijips's  series  of  100  cases, 

1.  Colon  opened  in  the  groin     . 

2.  Colon  opened  in  the  loin  .         .         . 

3.  Puncture       ...... 

4.  Coccyx  resected        .... 

5.  Perineal  incision  or  dissection 

6.  Communication  between  rectum  and  vagina 

7.  Miscellaneous 

Results  of  ojjerations  in  Anders's  series  of  100  cases. 

1.  Colon  opened  in  groin  .... 

2.  Colon  opened  in  loin 

3.  Littre's 

•4.  Puncture  .         .         .         .         .         . 

5.  Incision         ...... 

6.  Proctoplasty  (dissection)  .         . 

7.  Non-operable         ..... 

8.  Miscellaneous    . 


Lived 

Died 

16 

5 

11 

3 

1 

2 

17 

3 

14 

8 

3 

5 

39 

25 

14 

14 

13 

1 

3 

0 

3 

100 

50 

50 

100  cases. 

Lived  Died 

8 

4 

4 

3 

1 

2 

10 

5 

5 

4 

2 

2 

27 

18 

9 

44 

31 

13 

3 

2 

1 

1 

1 

0 

100 

eT 

86 

It  need  hardly  be  pointed  out  that  a  just  estimate  of  the 
value   to   be  attached   to   these  tables  can  only   be  formed 


MALF(JIIMATI0NS  668 

by  a  careful  analysis  of  the  cases  comprised  in  thera.  For 
the  extremely  variable  nature  of  the  malformations  is  such 
that  one  particular  operation  might  prove  more  frequently 
successful  in  one  type  than  in  another.  The  various  tables 
given  b}^  Anders  admit  of  this  investigation,  but  it  would 
occupy  too  much  space  to  introduce  them  or  to  attempt  to 
summarise  them  here. 

As  regards  the  remote  results  of  operation,  numerous  cases 
are  on  record  to  show  that  life  has  been  prolonged  for  months 
and  years.  As  illustrative  of  comparative  longevity  of  life, 
the  following  are  abstracted  from  Curling's  series  of  100  cases. 

Longevity  after  operation. 

1.  Lived  43  years  ;  died  of  other  troubles.  Ojjeration. — Colotomy  in 
groin. 

2.  Alive  and  vs^ell  at  43  years.     Operation. — Colotomy  in  groin. 

3.  Alive  and  vi^ell  at  46  years.     Operation. — Colotomy  in  groin. 

4.  Alive  and  well  at  36  years.  Operation. — Cul-de-sac  reached  and 
drawn  down  into  the  perineum,  and  artificial  anus  established  behind  the 
seat  of  natural  anus. 

5.  Alive  and  well  at  21  years.  Operation. — Incision  and  puncture,  and 
gut  reached. 

Among  the  more  recently  published  cases  are  the  follow- 
ing. Ball  ^  records  the  case  of  a  medical  man  operated  upon 
at  birth  for  imperforate  anus.  A  case  by  Moullin,^  where 
the  bowel  was  opened  in  the  left  inguinal  region  within  twenty- 
four  hours  of  birth.  The  child  lived  for  six  months,  and  then 
contracted  measles,  from  which  it  died.  At  the  post  mortem 
the  rectum  was  found  to  open  by  a  very  narrow  channel  into 
the  prostatic  portion  of  the  urethra.  In  a  case  recorded  by 
Stephen  Paget,^  the  author  was  enabled  to  effect  an  opening 
through  the  perineum  by  passing  a  director  through  the 
bowel  from  above  after  performing  colotomy.  The  child 
lived  five  weeks,  and  great  difficulty  was  encountered  in  keep- 
ing the  rectum  dilated.  Tn  my  own  case  described  below,  a 
sigmoid  anus  was  made,  and  a  subsequent  communication 
established  with  the  anal  cul-de-sac  by  a  director  passed 
through  the  artificial  anus.  The  child  lived  for  about  seven 
months,  and   then   contracted  scarlet    fever,  from  which   it 

'  Diseases  of  the  Rectum,  p.  42. 

2  Trans.  Path.  Soc.  Lond.  1886,  vol.  xxxvii.  p.  260. 

'  Ibid.  1890,  vol.  xli.  p.  143. 


664  THE   RECTUM 

died.  As  in  Paget's  case,  great  difficulty  existed  in  prevent- 
ing the  contraction  at  the  line  of  communication.  In  a  case 
recorded  by  Conant,'  the  abdomen  was  opened,  and  by  the 
aid  of  digital  manipulation  within  the  pelvis,  it  was  found 
possible  to  successfully  guide  a  trocar  into  the  distended 
rectum.  The  child  lived  for  three  months,  and  then  died  of 
entero-colitis. 


CHAPTER  LXXX 


MALFORMATIONS    {continued).        TREATMENT.       CONGENITAL 
STRICTURE.       DIVERTICULUM 

Treatment. — Clinically  these  malformations  present  them- 
selves under  two  distinct  classes— those  where  the  nature  of 
the  abnormality  is  evident,  and  those  where  it  is  not.  In 
discussing,  therefore,  the  treatment,  it  is  right  to  consider  it 
from  this  twofold  aspect ;  for  while  it  serves  admirably  the 
purpose  of  the  pathologist  to  classify  the  various  malforma- 
tions which  may  be  found,  it  is  not  of  much  practical  service 
to  the  surgeon,  who  in  many  cases  is  forced  to  perform  his 
operation  before  discovering  the  nature  of  the  deformity  for 
which  he  does  it. 

When  a  distinct  bulging  exists  or  an  impulse  is  distinctly 
felt  at  the  seat  of  an  occluded  anus,  or  at  the  apex  of  an  anal 
cul-de-sac,  the  surgeon  has  little  difficulty  in  deciding  that 
the  proper  course  to  pursue  is  to  make  a  small  crucial  or 
single  incision  into  the  projecting  mass  and  allow  the  escape 
of  the  pent-up  meconium.  Later,  if  considered  necessary, 
the  opening  thus  made  may  be  dilated  to  the  required  extent. 

When  meconium  is  passed  by  some  abnormal  channel,  the 
treatment  will  be  determined  by  the  troubles  caused.  Thus, 
if  it  is  possible  to  dilate  the  fistula  sufficiently  to  allow  of  a 
free  and  unobstructed  exit  of  the  meconium,  no  immediate 
danger  need  be  anticipated ;  but  if  such  dilatation  is  not 
possible,  and  obstruction,  if  not  present,  certain  to  appear 
sooner  or  later,  then  an  operation  which  otherwise  might  with 
advantage  have  been  delayed  must  be  performed. 

'  Boston  Med.  and  Surg.  Reporter,  1892,  vol.  cxxvi.  p.  287. 


MALFORMATIONS  60o 

If  the  meconium  passes  through  the  urethra,  the  rectal 
communication  is  either  with  this  canal  or  with  the  bladder. 
A  dissection  should  be  made  in  the  median  line  of  the  peri- 
neum. If  the  fistula  is  recto-urethral,  it  will  be  reached  and 
found  possible  to  disconnect  it.  The  bowel  should  then  be 
brought  down  and  fixed  in  the  perineum.  Should  the  result 
of  the  dissection  prove  negative,  it  is  then  probable  that  the 
fistula  is  recto-vesical,  and  nothing  but  a  sigmoid  anus  will 
give  the  requisite  relief. 

If  the  meconium  come  through  the  vulva,  a  vaginal  fistula 
is  present.  Eegarding  the  treatment  of  this  condition  some 
difference  of  opinion  exists.  If  a  well-marked  sphincter  guards 
the  orifice  of  the  vaginal  anus,  it  may  be  well  to  leave  the  case 
alone  rather  than  run  the  risk  of  losing,  by  dissection  and 
transplantation,  this  power  of  control.  If  operation  is  at- 
tempted, the  most  successful  appears  to  be  that  devised  and 
carried  out  by  Rizzoli.  Its  main  object  is  to  dissect  back  the 
rectum,  and  preserve  the  tissues  around  the  vaginal  orifice 
which  may  act  as  a  sphincter.  The  operation  is  commenced 
by  an  incision  carried  from  the  lower  margin  of  the  vaginal 
anus  backwards  towards  the  coccyx.  The  rectum  is  then 
detached,  care  being  taken  not  to  open  the  bowel,  and  the 
vaginal  orifice  stitched  into  the  place  where  the  normal  anus 
should  be  situated.  Deep  sutures  are  inserted  to  close  in 
the  posterior  part  of  the  vaginal  wall,  and  so  form  a  recto- 
vaginal septum. 

If  there  is  no  immediate  urgency  these  plastic  operations 
may  with  advantage  be  left  until  the  child  is  older  and  there- 
fore better  fitted  for  operation.  Swaine  ^  very  successfully 
treated  a  child  6  years  old,  which  had  passed  all  its  faeces  by  a 
vaginal  anus.  On  account  of  much  abdominal  swelling,  a 
faecal  fistula  was  formed  in  the  groin.  After  an  interval,  the 
rectum  was  dissected  from  the  vagina  and  brought  down  to 
the  perineum  and  a  true  anus  established.  The  fistula  then 
healed. 

When  external  fistulae  exist  either  in  the  perineum  or 
scrotum,  there  may  not  be  need  for  immediate  interference. 
It  must  be  remembered  that  in  so  young  a  class  of  patients 
all  delay  is  valuable  with  a  view  to  the  safety  and  success  of 

'  Laiicet,  1891,  vol.  i.  p.  143. 


666  THE  RECTUM 

any  operation,  as  long  as  it  does  not  entail  a  less  suitable 
state  of  the  child's  general  condition.  If  on  the  other  hand  the 
nature  of  the  malformation  involves  increasing  gravity  in  the 
condition  of  the  child,  the  sooner  operation  is  performed  the 
better.  Should  the  fistulse  in  this  class  of  cases  not  suffice  to 
allow  of  a  free  discharge,  they  should  be  either  enlarged  or  a 
perineal  dissection  made  to  obtain  the  more  dilated  portion  of 
the  bowel. 

What  treatment  is  to  be  adopted  when  the  surgeon  has  no 
distinct  guidance  as  to  the  type  of  the  malformation  present  ? 
To  very  many  cases  which  present  themselves  for  treatment 
this  question  is  applicable. 

The  usually  accepted  course  to  pursue  is  to  make  an  in- 
cision backwards  from  the  normal  seat  of  the  anus  to  the 
coccyx,  removing  this  if  thought  necessary,  and  continuing 
to  extend  the  incision  deeply  and  in  the  direction  of  the 
concavity  of  the  sacrum.  If  a  reasonable  dissection  of  this 
nature  fails  to  reach  the  bowel,  there  is  nothing  for  it  but 
to  make  an  artificial  anus  either  in  the  groin  or  in  the  loin. 
If  on  the  other  hand  the  rectal  cul-de-sac  is  reached,  an 
endeavour  should  be  made  to  bring  the  rectal  outlet  to  the 
surface  and  stitch  it  there.  In  cases  where  this  involves 
much  tension  on  the  bowel,  the  coccyx  may  be  removed,  and 
so  the  distance  to  the  surface  shortened.  While  an  incision 
into  the  bowel  will  for  the  time  relieve  the  child,  it  soon  be- 
comes little  more  than  a  troublesome  fsecal  fistula ;  hence  the 
advantage  attached  to  fixation  of  the  rectal  orifice  to  the  skin 
surface. 

As  regards  searching  for  the  bowel  by  dissection  in  the 
perineum,  it  should  be  remembered  that  in  cases  where  there 
is  deficiency  of  development  of  the  pelvis  as  a  whole,  there  is 
the  greater  probability  that  the  rectum  may  be  entirely  absent 
or  occupying  a  high  limit. 

When  it  is  decided  to  open  the  bowel,  should  a  colostomy 
be  performed  or  an  artificial  anus  made  ?  From  my  own 
experience  I  am  disposed  to  favour  the  formation  of  an  arti- 
ficial anus,  and  for  this  reason,  that  the  bowel  of  an  infant 
is  so  thin,  and  more  particularly  so  if  it  has  been  distended, 
that  it  is  difficult  to  accurately  stitch  it  to  the  parietal  wound  ; 
and  if,  as  is  usually  the  case,  it  must  be  opened  at  once,  the 


MALFORMATIONS  667 

thin  meconium  is  liable  to  contaminate  the  surface  of  the 
bowel  and  find  its  way  into  the  peritoneal  cavity.  If  on  the 
other  hand  a  loop  of  intestine  is  withdrawn  and  secured  by  a 
rod  of  some  kind  passed  transversely  through  the  mesentery, 
and  a  drainage  tube  fixed  into  the  upper  end  of  the  loop  in 
such  a  way  that  the  meconium  can  only  escape  through  it, 
there  is  little  or  no  danger  of  septic  infection.  It  has  also 
the  further  great  advantage  that  a  much  shorter  time  is  re- 
quired to  make  an  anus  than  to  make  a  fistula  such  as  results 
from  a  colostomy.  The  only  objection  which  the  method  has 
is  the  difficulty  of  closing  the  anus  as  compared  with  the 
fistula,  if  such  be  required.  It  is  more  than  likely,  however, 
that  if  it  is  possible  for  the  patient  to  live  for  any  length  of 
time,  he  will  be  more  likely  to  do  so  with  a  good  artificial 
anus  than  with  one  which  has  been  subsequently  opened  up 
in  the  perineum,  and  which  shows  a  constant  tendency  to 
contract  and  close. 

It  is  usual  to  operate  in  the  left  groin  with  the  object  of 
opening  the  sigmoid  flexure.  In  these  cases  of  defective 
development,  however,  it  not  infrequently  happens  that  the 
sigmoid  does  not  lie  in  its  normal  position.  If  therefore 
this  part  of  the  bowel  cannot  be  found,  the  surgeon  must 
either  secure  any  distended  loop  which  presents,  or  else  close 
the  original  wound  and  open  in  the  right  groin. 

The  question  is  often  raised  whether,  after  the  bowel  is 
opened  in  the  groin,  any  attempt  should  at  once  be  made  to 
open  up  the  perineal  passage  by  a  bougie  or  director  passed 
in  and  downwards  through  the  bowel  orifice.  Such  treatment 
has  been  adopted  and  with  success,  as  already  instanced  by 
Paget's  case,  where  the  child  lived  for  five  weeks  afterwards. 
Possibly  such  a  course  is  right  when  the  infant's  condition 
admits  of  the  prolongation  of  the  operation,  and  when  it  is 
felt  that  the  apex  of  the  bougie  is  at  no  great  distance  from 
the  normal  seat  of  the  anus  or  the  anal  cul-de-sac.  But  for 
this  latter  condition  there  is  the  danger  that  the  rectal  cul- 
de-sac  may  be  surrounded  by  peritoneum,  and  so  its  perfora- 
tion lead  to  a  communication  with  the  general  peritoneal 
cavity.  The  one  advantage  of  attempting  this  method  of  esta- 
blishing a  normal  channel  at  the  first  operation  rather  than 
delaying  it  for  future  treatment,  is  the  ease  with  which  it  is 


663  THE   RECTUM 

possible  to  close  up  the  opening  in  the  colon.  The  difficiiltj'' 
later  would  not  exist  so  much  with  a  colostomy ;  but  with 
an  artificial  anus,  an  operation  entailing  considerable  risk 
would  have  to  be  added  to  what  so  far  may  have  proved 
successful. 

Nothing  has  as  yet  been  said  of  the  treatment  of  many  of 
these  cases  by  puncture  or  the  use  of  the  trocar  and  canula. 
The  practice  was  much  in  vogue  many  years  ago,  but  experi- 
ence has  sufficiently  shown  that  it  is  one  of  the  most  dangerous 
methods  to  employ.  A  reference  to  Cripps's  and  Anders's  sta- 
tistics of  operations  (see  p.  662)  will  sufficiently  indicate  how 
fatal  this  method  of  operating  has  been  in  comparison  with 
others.  The  fatality  in  connection  with  it  is  largely  dependent 
upon  the  fact  that  there  is  nothing  to  guide  the  operator  in 
avoiding  the  injury  which  he  is  liable  to  inflict.  The  trocar 
may  be  passed  directly  into  the  peritoneal  cavity,  or  traverse 
the  rectal  cul-de-sac  and  then  enter  the  peritoneal  cavity.  In 
illustration  of  such  accidents,  two  cases  may  be  cited,  one 
recorded  by  Cripps  ^  and  the  other  by  J.  J.  Clarke.^  In  the 
case  of  the  former,  the  puncture  had  passed  into  the  apex 
of  the  peritoneal  pouch  upwards,  parallel  to  the  bowel  ; 
peritonitis  ensued,  from  which  the  child  died.  In  the  case  of 
the  latter,  the  trocar  entered  the  peritoneal  cavity  by  passing 
through  the  lowest  extremity  of  the  rectum.  Death,  however, 
ensued  from  hasmorrhage,  the  result  apparently  of  injury  to 
the  sacra-media  artery.  At  the  necropsy,  meconium  was  found 
in  the  peritoneal  cavity. 

Other  methods  of  treatment  are  sometimes  adopted,  such 
for  instance  as  that  employed  in  Conant's  case.  The  abdo- 
men was  opened  in  the  left  linea  semilunaris.  Distended 
bowel  was  detected  extending  towards  the  perineal  incision. 
It  seemed  about  a  quarter  of  an  inch  from  this  incision,  which 
had  been  previously  made  in  search  for  the  bowel.  By  the 
guidance  of  one  finger  in  the  abdomen,  a  trocar  was  success- 
fully thrust  through  the  perineal  wound  into  the  distended 
gut.  Five  ounces  of  meconium  passed  by  the  canula.  The 
abdominal  wound  was  closed,  and  the  canula  fastened  in  by 


Trans.  Path.  Soc.  Lond.  vol.  xxxi.  p.  112. 
Lancet,  1891,  vol.  li.  p.  1277. 


MALFOllMATIONS  669 

plaster.     The  child  improved,  but  died   three  months  after 
from  entero-cohtis. 

Case  CXV. — Anal  cul-de-sac,  rectum  imperforate  :  sigmoid  anus  :  sub- 
sequent opening  into  rectum  from  ijerineum.  Death  in  seven 
■months  from  scarlet  fever. 

The  child  was  born  on  Thursday,  April  25.  On  Friday,  May  6 
(eleven  days  after  birth),  it  was  brought  to  the  Victoria  Infirmary,  Glasgow. 
It  was  stated  that  it  had  passed  nothing  by  the  anus.  Castor  oil  had  been 
given  without  effect  and  enemas  had  been  tried,  but  the  fluid  was  found 
to  return  immediately.  It  had  never  vomited.  On  examining  the  abdo- 
men much  distension  was  observed.  A  catheter  introduced  into  the  anus 
did  not  pass  for  more  than  an  inch.  The  child  was  emaciated  and  suffered 
from  doiible  purulent  ophthalmia.  The  pelvis  appeared  unduly  small, 
and  the  ischial  tuberosities  abnormally  close  together. 

Op)eration. — After  chloroform  was  admmistered,  the  anal  cul-de-sac 
was  carefully  examined,  but  no  bulging  of  bowel  could  be  detected.  A 
tenotomy  knife  was  thrust  in  for  about  an  inch,  and  an  incision  carried 
backwards  towards  the  sacrum.  Nothing,  hoAvever,  was  detected.  A 
left  sigmoid  anus  was  then  made.  It  was  intended  at  first  not  to  open 
the  bowel,  but  owing  to  the  failure  of  respiration,  and  the  critical  state 
which  the  child  seemed  to  be  in,  an  opening  was  made  into  the  loop,  when 
a  large  quantity  of  gas  at  once  escaped,  and  the  child's  condition  imme- 
diately began  to  improve  and  no  further  trouble  occurred. 

On  July  18,  about  ten  weeks  after  the  first  operation,  a  bougie  was  passed 
down  the  rectima  from  the  artificial  anus.  The  point  was  felt  compara- 
tively near  the  apex  of  the  anal  cul-de-sac,  and  an  incision  made  upon 
it  sufficiently  large  to  admit  of  an  indiarubber  tube  being  inserted. 
This  was  sufticiently  long  to  admit  of  being  passed  through  the  rectum 
and  out  at  the  sigmoid  anus,  and  the  two  free  ends  fastened  together. 

On  November  8  the  artificial  line  of  communication  had  contracted 
into  such  a  tight  stricture  that  it  was  necessary  to  divide  it.  A  vulcanite 
rectal  pessary  was  tied  in,  and  this  appeared  to  be  having  a  beneficial 
effect,  when  the  child  contracted  scarlet  fever  and  died.  (A.  Ernest 
Maylard,  '  Glasgow  Med.  Journ.'  1896,  No.  2,  vol.  xlv.  p.  120.) 

Congenital  stricture. — The  term  *  congenital  stricture  '  im- 
plies not  necessarily  that  a  stricture  existed  at  birth,  only  that 
the  conditions  involving  its  subsequent  development  were  pre- 
sent. These  cases  are  usually  included  under  those  just 
described,  inasmuch  as  they  are  the  result  either  of  defective 
development  of  the  anal  or  lower  rectal  portion  of  the  canal, 
or  of  treatment  employed  in  remedying  some  of  the  more 
serious  obstructive  malformations.  When  arising  as  the 
result  of  incomplete  development,  the  stricture  takes  the 
form  either  of  a  canal  which  has  remained  too  narrow  for 


670  THE   RECTUM 

the  purposes  required ;  or  the  septum  which  normally  divides 
the  anal  and  rectal  portions  of  the  gut  has  only  been  imper- 
fectly removed,  so  that  either  a  simple  orifice  exists  in  it,  or  a 
part  remains  in  the  form  of  a  valve.  According  to  Trelat,' 
who  records  having  seen  five  instances  of  this  valvular  form 
of  obstruction,  the  usual  seat  of  the  stricture  is  about  five 
centimetres  from  the  anus.  The  stricture  may  escape  notice 
for  many  years  ;  and  not  until  age  lessens  the  general  elas- 
ticity of  the  tissues,  and  the  faeces  become  larger  and  more 
solid,  do  symptoms  of  obstruction  and  difficulty  in  defecation 
arise.  These  symptoms  differ  in  no  respect  from  those  already 
described  as  arising  from  innocent  or  non-malignant  stenosis  ; 
abscess  and  fistulse  may  result ;  or  ulceration  and  faecal  extra- 
vasation may  lead  to  periproctitis. 

Strictures  which  arise  as  the  result  of  operations  joerformed 
to  open  up  the  continuity  of  the  canal  in  cases  of  imperforate 
anus  or  rectum,  or  as  the  result  of  transplanting  the  rectum 
from  the  vagina  or  the  urethra  to  the  perineum,  are  often 
among  the  most  troublesome.  They  are  essentially  cicatricial 
strictures  and  therefore  extremely  tight.  Good  instances  of 
these  are  seen  in  the  case  narrated  above  in  full,  and  in  Paget's, 
also  quoted  above.  The  simjjlest  form  of  cicatricial  stricture 
arising  from  operation  is  such  as  may  be  met  with  after  incision 
for  atresia  ani.  In  the  case  recorded  by  Ball  ^  of  a  medical 
man  who  had  been  operated  upon  at  birth  for  imperforate  anus, 
a  comparatively  slight  constriction  was  felt  just  within  the 
anus,  through  which  the  finger  readily  passed. 

Little  need  be  said  regarding  the  treatment  of  these  cases  ; 
for  if  simple  dilatation  or  incision  of  the  stricture  is  not  suffi- 
cient, it  must  be  treated  on  the  lines  already  laid  down  for 
stricture  arising  from  other  non-malignant  causes. 

Diverticulum. — True  diverticula  of  the  rectum  are  extremely 
rare.  I  have  only  met  with  four  recorded  instances.  In  1873 
Hulke  ^  published  a  case.  The  diverticulum  was  situated  on 
the  side  of  the  rectum,  running  parallel  with  it.  It  was  large 
enough  to  admit  the  finger  easily,  and  was  several  inches  in 


'  Kelsey,  Annual  of  the  Universal  Medical  Sciences,  1888,  vol.  ii.  p.  148. 

^  Diseases  of  the  Rectum,  p.  48. 

8  Trans.  Path.  Soc.  Lcjul.  1873,  vol.  xxiv.  p.  87. 


MALFOIIMATIONS       -  671 

length.     In   structure  it   possessed    a  mucous  lining   and    a 
muscular  coat. 

In  1887  Ball  '  published  a  case  in  his  work  upon '  Diseases 
of  the  Kectum.'  Strangely,  the  author  introduces  the  case  as  a 
unique  one  in  his  chapter  on  Malformations,  but  in  a  short 
chapter  at  the  end  of  the  book  on  the  subject  of  diverticula  no 
notice  is  taken  of  it.  The  case  was  that  of  a  medical  man  who 
developed  a  swelling  at  the  root  of  the  penis  and  deep  in  the 
scrotum.  He  had  suffered  from  pain  while  the  bowels  were 
being  moved.  When  the  rectum  was  examined,  a  diverticulum 
was  detected  passing  off  in  the  direction  of  the  situation  of  the 
abscess,  that  is  to  say,  forwards  towards  the  urethra.  The 
patient  had  suffered  at  birth  from  atresia  of  the  anus,  and 
slight  constriction  of  the  anal  orifice  had  resulted.  It  is  stated 
that  after  the  abscess  was  opened  and  the  membranous  stric- 
ture dilated,  the  diverticulum  became  closed,  so  that  the 
patient  ultimately  was  cured.  The  want  of  some  more  exact 
evidence  than  that  which  the  narration  of  the  case  affords, 
raises  some  doubt  as  to  its  being  one  of  true  diverticulum. 
The  presence  of  a  stricture,  and  a  fetid  abscess  in  the  peri- 
neum in  communication  with  the  bowel  just  above  the  stricture, 
strongly  suggests  that  the  one  has  been  the  result  of  the  other, 
and  that  an  ordinary  fistula  in  ano  was  in  process  of  forma- 
tion. Possibly  some  such  opinion  existed  in  the  mind  of  the 
author,  and  so  it  was  not  introduced  as  an  illustration  of  the 
condition  in  the  short  chapter  especially  devoted  to  the  subject. 

In  1888  Maas  ^  reported  a  remarkable  case  of  an  immense 
diverticulum.  The  patient  was  a  boy  aged  14.  Shortly  after 
birth  the  abdomen  began  to  swell,  and  continued  to  increase 
in  size  as  he  grew  older.  He  remained  well  until  the  age 
of  13.  The  abdominal  distension  then  commenced  to  cause 
dyspnoea  and  palpitation.  The  boy  died  suddenly,  when  at 
the  post  mortem  an  immense  diverticulum  was  found  arising 
from  the  upper  part  of  the  rectum.  It  contained  gas  and 
fourteen  litres  of  thin  faeces. 

In  1889  Terrier  ^  recorded  an  interesting  case  in  which 
the  diverticulum  was  successfully  excised.     The  patient  had 

•  P.  42. 

^  Kelsey,  Annual  of  the  Universal  Medical  Sciences,  1889,  vol.  iii.  D— 2. 
^  Rnme  de  Cliirurgie,  1889,  vol.  ix.  p.  929. 


672  THE    RECTUM 

suffered  during  life  from  a  constant  sense  of  weight  in  the 
rectum.  A  fulness  was  observed  externally  in  the  right  ischio- 
rectal fossa  ;  and  on  introducing  the  finger  it  could  be  made 
to  enter  a  contracted  orifice  which  led  into  a  diverticulum  on 
the  right  side,  filled  with  faeces.  The  rectum  itself  was  dilated. 
The  diverticulum  was  removed,  and  the  dilated  bowel  also 
narrowed.  The  patient  made  a  good  and  uninterrupted  re- 
covery. 


CHAPTEK   LXXXI 

NEUROSES.       EXTERNAL    INFLUENCES 

While  much  has  been  written  upon  the  subject  of  neurotic 
affections  of  the  rectum,  most  men  appear  practically  to  have 
seen  but  little  of  them.  Judging  from  the  literature  on  the 
subject,  the  object  of  many  writers  appears  to  be  to  refute 
rather  than  to  support  the  theory  that  such  affections  exist. 
Van  Buren,^  in  an  exhaustive  article  upon  what  he  terms 
*  phantom  strictures,'  introduces  numerous  instances  in  which 
patients  were  led  to  believe,  either  through  their  own  aberrant 
nervous  condition  or  as  the  result  of  ignorant  and  ground- 
less suggestion,  that  rectal  trouble  existed,  and  were  treated 
accordingly.  Indeed,  many  years  ago,  supposed  strictures 
of  the  rectum  seemed  a  sort  of  fashionable  complaint,  for  which 
the  systematic  passage  of  bougies  was  considered  the  proper 
treatment. 

In  addition  to  these  imaginative  cases,  there  is  little  doubt 
that  a  great  many  cases  of  so-called  neuralgia  of  the  rectum 
have  their  explanation  in  the  existence  of  some  organic  lesion. 
Either  the  pain  is  set  up  by  a  small  ulcer  or  abrasion,  in  the 
floor  of  which  a  sensitive  nerve  filament  is  exposed  ;  or  the 
pain  is  excited  reflexly  by  disease  situated  in  some  neigh- 
bouring organ  or  tissue.  If  a  case  is  to  be  considered  one  of 
true  neuralgia,  a  careful  examination  should  reveal  no  lesion 
to  account  for  the  pain,  nor  should  the  patient's  sufferings  be 
in  any  way  affected  by  defecation. 

The  class  of  patients  supposed  to  be  the  subject  of  these 

'  American  Journal  of  ilic  Medical  Sciences,  1879,  N.S.  vol.  Ixxviii. 
p.  83G. 


NEUHOSES— EXTERNAL   INFLUETsCES  673 

neurotic  affections  are  usually  females  of  feeble  constitution  and 
of  a  more  or  less  depressed  state  of  the  nervous  system.  The 
pains  attending  them  are  described  as  often  excessively  acute  and 
lancinating  and  sometimes  periodical  in  their  mode  of  seizure. 
Allingham,'  who  is  largely  quoted  as  a  believer  in  rectal 
neuralgia,  mentions  having  noticed  the  attack  follow  direct 
exj^osure  to  wet  and  cold,  as  after  sitting  upon  damp  grass. 

In  treating  the  condition  attention  should  be  devoted  to 
the  general  health,  and  such  remedies  and  directions  given  as 
would  be  considered  expedient  and  suitable  in  patients  that 
possess  in  all  probability  an  irritable  and  neurotic  tempera- 
ment. In  a  very  obstinate  case  of  nervous  or  hysterical 
rectum  reported  by  Mathews, ^  where  the  patient,  a  young 
lady,  suffered  from  attacks  of  '  sharp,  quick,  lancinating, 
terrible  pain  just  within  the  rectum,  lasting  for  a  few  minutes 
to  several  hours,'  the  symptoms  subsided  with  enemata  of  cold 
water  when  all  other  means  had  failed.  Allingham's  line  of 
treatment  is  first  to  unload  and  put  the  abdominal  viscera 
into  condition,  then  give  tonics  such  as  iron,  quinine,  and 
strychnia,  with  morphia  hypodermically  for  the  pain.  While 
some  cases  improve  rapidly  under  treatment,  others  appear 
intractable,  the  attacks  of  pain  recurring  from  time  to  time. 

External  influences. — The  rectum,  like  all  other  parts  of 
the  intestinal  canal,  is  liable  to  be  pressed  upon,  displaced, 
distorted  or  opened  into  by  agencies  acting  from  without,  and 
primarily  unconnected  with  the  bowel. 

Pressure  may  result  from  an  enlarged  prostate,  or  from 
an  abscess  connected  with  the  prostate  :  from  tumours  grow- 
ing from  the  uterus,  ovary,  bladder,  or  sacrum.  Displacement 
or  distortion  may  be  due  to  similar  causes,  or  to  inflammatory 
action,  as  seen  in  pelvic  cellulitis.  Abscesses,  both  acute  and 
chronic,  may  burst  into  the  rectum,  giving  rise  to  the  dis- 
charge of  pus  and  blood,  more  or  less  continuous  according  to 
the  nature  of  the  primary  disease.  Chronic  abscesses  are 
such  as  arise  from  caries  of  the  bones  of  the  pelvis  ;  caries  of 
the  spine  producing  a  psoas  abscess  ;  abscess  in  connection 
with  hip  joint  disease.  Acute  abscesses  may  be  the  result 
of  pelvic  cellulitis,  pelvic  appendicitis,  prostatic  abscess  from 
gonorrhoea,  &c, 

'  Diseases  of  the  Rectum,  p.  324.  -  Ibid.  p.  257. 

X    X 


674  THE   RECTUM 

In  illustration  of  some  of  these  causes  the  following 
instances  may  be  cited. 

Van  Buren  ^  records  a  case  of  uterine  fibroma  which  pro- 
duced symptoms  of  obstruction.  The  case  was  that  of  a  young 
lady  who  could  not  relieve  her  bowels  whilst  sitting  in  the 
usual  position,  and  in  order  to  do  so  &he  had  been  compelled 
to  resort  to  the  use  of  a  bed-pan,  taking  an  enema  and  then 
lying  upon  her  back.  A  digital  examination  of  the  rectum, 
made  while  she  was  in  the  sitting  position,  revealed  the  pre- 
sence of  a  globular  tumour  which  became  forced  backwards 
into  the  hollow  of  the  sacrum,  so  as  to  comj)letely  obstruct 
the  passage  through  the  rectum.  The  tumour  subsequently 
proved  to  be  a  fibroma  attached  to  the  posterior  wall  of  the 
uterus.  A  somewhat  similar  case  is  recorded  by  Sydney  Jones,^ 
in  which  a  large  uterine  fibroid  pressed  upon  the  rectum  and 
caused  serious  interference  with  the  action  of  the  bowels. 

When  rectal  troubles  arise  in  connection  with  pelvic 
cellulitis,  the  inflammation  leads  either  to  the  formation  of 
an  acute  abscess,  or  to  a  more  chronic  process  involving  much 
inflammatory  thickening  and  contraction.  In  the  former  case 
the  abscess  may  burst  into  the  bowel,  and  produces  for  the 
time  no  more  serious  rectal  symptoms  than  the  discharge  of  a 
quantity  of  blood  and  pus  which  ceases  as  the  abscess  cavity 
closes  and  heals.  In  the  latter  case,  however,  the  greater 
slowness  of  the  process  may  result  in  the  formation  of  ad- 
hesions and  fibrous  bands  which  compress,  drag  upon,  or 
displace  the  bowel  from  its  usual  position,  and  lessen  its 
normal  function  as  a  more  or  less  uniformly  distensible 
canal.  The  sequel  to  these  influences  is  in  some  cases  a  well- 
marked  fibrous  stricture  ;  for  while  the  cause  is  at  first  situated 
external  to  the  bowel,  its  parietes  soon  become  directly  in- 
volved, and  changes  take  place  in  it  which  lead  to  a  condition 
indistinguishable  from  any  arising  primarily  within  the  gut 
wall.  Cripps  ^  describes  the  case  of  a  woman  who  a  month 
after  being  seized  with  pelvic  cellulitis  had  a  discharge  of 
blood  and  pus  from  the  rectum.  This  continued  rather  pro- 
fusely for  some  weeks,  when  she  began  to  have  difficulties 

'  American  Journal  of  the  Medical  Sciences,  1879,  N.S.  vol.  Ixxviii.  p.  336. 
«  Trans.  Path.  Soc.  Lond.  1887,  vol.  xxxviii.  p.  247. 
»  Ibid.  1&86,  vol.  xxxvii.  p.  255. 


EXTERNAL    INFLUENCES  675 

in  defecation.  The  symptoms  continued  and  increased  until 
a  year  later,  when  a  tight  stricture  could  be  felt,  starting 
about  three  inches  up  from  the  anus.  She  died  about  a 
month  later,  when  a  well-marked  fibrous  stricture  was 
observed,  involving  about  six  inches  of  the  bowel.  At  the 
bottom  of  Douglas's  pouch  there  was  a  well- marked  cicatrix, 
apparently  indicating  the  site  of  an  old  abscess  cavity  in  the 
fascia  between  the  peritoneum  and  the  rectum.  The  rectum 
opposite  this  point  appeared  to  have  been  dragged  upon 
and  drawn  towards  the  cicatrix  mentioned.  The  following 
case,  which  is  given  more  fully,  is  interesting  as  showing  to 
what  an  extreme  degree  the  rectum  may  be  involved  in  this 
affection. 

Case  CXVI. — Double  stricture  of  the  rectum  from  j^elvic  cellulitis  : 
acute  obstruction.     Death. 

A  woman  aged  50  had  suffered  constantly  from  pelvic  and  rectal  pain, 
with  increasing  difficulty  in  defecation  ever  since  an  attack  of  pelvic 
cellulitis  four  years  previously.  For  the  last  year  and  a  half  she  had 
been  troubled  with  attacks  of  diarrhoea,  and  the  occasional  passage  of 
blood.  On  examination  of  the  rectum  a  mass  of  cartilaginous  firmness 
was  felt  connected  with  the  uterus  behind,  and  completely  blocking  the 
bowel  by  pressing  it  against  the  sacrum.  Eelief  was  afforded  by  the 
passage  of  a  catheter  tlirough  the  stricture,  but  the  sensation  conveyed  was 
always  that  a  second  one  existed  higher  up.  The  patient  refused  to  have 
an  artificial  anus  made,  and  lived  a  miserable  existence  for  two  years, 
finally  having  an  attack  of  acute  obstruction,  from  which,  however,  she 
recovered,  only  to  die  shortly  after  from  uraemia.  At  the  post  mortem, 
the  anterior  surface  of  the  uterus  and  the  bladder  were  free  from  any 
exudation  ;  but  both  ovaries  and  broad  ligaments,  the  rectuin  and  Douglas's 
pouch  were  solidly  embedded  and  all  firmly  cemented  to  the  sacrum  and 
coccyx.  About  an  inch  and  a  half  above  the  first  seat  of  obstruction  a 
second  was  discovered,  caused  by  a  distinct  band  which  had  twisted  the 
bowel  on  itself  and  bound  it  firmly  down  to  the  top  of  the  sacrum.  In 
the  space,  between  the  uterus  and  rectum,  there  was  an  abscess  cavity 
containmg  black  sloughy  tissue.  The  existence  of  this  had  not  been 
detected  during  life.  (Kelsey,  '  New  York  Med.  Joum.'  1887,  vol.  xlvi. 
p.  435.) 

Abscess  arising  in  connection  with  the  prostate  may  be 
either  of  an  acute  or  chronic  character.  When  acute,  it  is 
frequently  the  result  of  gonorrhoea,  and  causes  not  only 
difficult  but  painful  defecation.  The  urethra  is  also  liable 
to  be  pressed  upon,  so  that  urinary  trpuble   is   often  asso- 

X  X  2 


676  THE   RECTUM 

ciated  with  the  rectal.  Henry  Smith '  narrates  the  case  of 
a  man  aged  25  years  who  had  passed  nothing  for  a  week, 
and  was  in  continual  suffering.  A  fluctuating  swelling  was 
detected  in  front  of  the  bowel,  which  it  almost  occluded. 
When  incised  pus  escaped  and  all  syinptoms  subsided. 

Tumours  of  the  bladder  capable  of  producing  obstruction 
are  rare,  but  cases  have  been  recorded.  Hurry  Fenwick^ 
quotes  a  case  of  Obre's  in  which  a  large  hydatid  situated  in 
the  meso-rectum  led  to  death  from  obstruction.  The  pres- 
sure was  so  great  that  it  produced  sloughing  of  the  coats  of 
the  bowel  at  the  part.  Other  cases  of  hydatids  in  the  pelvis 
are  referred  to,  where  difficulty  in  both  defecation  and  mic- 
turition were  present. 


CHAPTER   LXXXn 

OPEKATIONS 

1.  THE    ADMINISTRATION    OF    COPIOUS    FLUID    ENEMATA. 

2.  THE    PASSAGE    OF    BOUGIES,    &C. 

3.  INTERNAL    PROCTOTOMY. 

4.  EXTERNAL    (LINEAR    OR    POSTERIOR)    PROCTOTOMY. 

5.  PROCTECTOMY — 

a.  PERINEAL 

b.  SACRAL    OR    POSTERIOR 
C.    VAGINAL. 

6.  PROCTORRHAPHY. 

7.  PROCTOPEXY. 

8.  PROCTOPLASTY. 

9.  RECTAL  ELECTROLYSIS. 
10.  RECTAL  CAUTERISATION. 

Many  of  the  operations  upon  the  rectam  are  of  limited  applica- 
tion, being  employed  for  some  one  special  condition  of  the  part 
itself ;  hence,  as  contrasted  with  the  oesophagus,  the  stomach 
and  the  intestines,  the  operations  are  mostly  described  at  the 
end  of  the  disease,  of  which  they  constitute  the  appropriate 
treatment.  Thus  operations  for  prolapse  and  for  many  mal- 
formations are  essentially  peculiar  to  the  affections,  and  are 

>  Holmes's  System  of  Surgery,  1883,  3rd  edit.  vol.  ii.  p.  858. 
^  Trans.  Path.  Soc.  Loncl.  1891,  vol.  xlii.  p.  210. 


OPERATIONS  677 

applicable  as  treatment  to  no  other  conditions.  The  operations 
of  proctotomy  and  proctectomy,  on  the  other  hand,  are  per- 
formed for  more  than  one  affection,  and  hence  rank  in  the 
same  category  as  like  operations  in  other  parts  of  the  ali- 
mentary tract ;  they  are,  in  a  sense,  classical  operations,  arjd 
call  for  separate  treatment. 

1.  The  administration  of  copious  fluid  enemata. — The  object  in 
view  may  be  (1)  to  excite  peristaltic  action  in  the  intestines, 
(2)  to  empty  and  cleanse  the  lower  bowel,  (3)  for  purposes  of 
diagnosis.  When  it  is  merely  desired  to  excite  the  bowels  to 
act,  the  fluid  will  be  best  injected  by  means  of  a  Higginson's 
syringe,  with  the  patient  in  the  sitting  posture  over  the  stool. 
The  sudden  and  forcible  injection  of,  say,  warm  soap  and  water 
soon  evokes  a  desire  to  empty  the  bowel. 

If  the  object  is  both  to  empty  and  cleanse  the  rectum  pre- 
liminary to  operation,  the  enema  is  best  administered  while 
the  patient  is  lying  on  the  back  with  the  buttocks  slightly 
raised  and  resting  upon  the  bed  pan.  A  gum  elastic  urethral 
catheter  of  No.  10  or  12  size,  lubricated  with  vaseline,  and 
having  attached  to  its  free  end  a  rubber  tube  about  three 
feet  in  length,  is  gently  inserted  into  the  anus,  and  made  to 
pass  as  far  as  possible  up  the  rectum.  To  the  other  end  of 
the  tube  is  fixed  a  filler  or  funnel.  This  is  held  up  about  two 
feet  above  the  bed  and  the  fluid  allowed  to  flow  in  slowly. 
The  object  in  view  is  not  to  excite  peristaltic  action  before  the 
bowel  has  been  well  distended,  and  its  mucous  folds  put  more 
or  less  on  the  stretch.  By  so  stretching  the  part  it  is  much 
more  efficiently  cleansed,  and  any  fsecal  particles  which  may 
be  lodged  in  folds  or  small  recesses,  or  be  unduly  adherent  to 
the  lining  membrane,  will  be  detached  and  ejected  with  the 
outflowing  fluid. 

When  injecting  fluid  into  the  rectum  for  diagnostic  pur- 
poses, the  same  precautions  should  be  exercised  in  not  intro- 
ducing it  too  quickly  or  too  forcibly.  The  object  may  be  to 
ascertain  the  locality  of  a  stricture  either  high  up  in  the 
rectum,  or  in  the  colon  ;  to  excite  peristaltic  action  too  readily 
or  too  soon  would  be  to  frustrate  the  object  for  which  the 
injection  was  being  given. 

2.  The  passage  of  bougies  &c. — A  bougie  is  introduced  into 
the  rectum  either  for  diagnostic  purposes  or  for  treatment. 


678  THE   RECTUM 

When  with  the  former  object,  a  large-size  one  is  introduced, 
in  order  to  detect  in  the  first  place  whether  there  is  any  real 
obstruction. 

For  the  passage  of  a  bougie  any  one  of  the  three  positions 
for  making  a  rectal  examination  may  be  employed,  the  lateral, 
lithotomy,  or  knee^elbow  position.  The  lateral  will  frequently 
prove  the  most  convenient.  The  patient  lies  on  the  left  side 
with  one  or  both  knees  drawn  up.  Preferably  the  rectum 
should  be  first  emptied  by  a  copious  fluid  enema.  A  little  oil 
containing  opium  or  belladonna  is  injected,  to  facilitate  the 
passage  of  the  bougie,  and  to  allay  any  irritability  of  the 
rectum.  To  further  ease  the  introduction  of  the  bougie  it 
should  be  besmeared  with  some  tenacious  lubricant  such  as 
Unguentum  Hydrargyri.  No  force  should  be  employed,  and 
as  any  obstruction  is  met  with  the  bougie  should  be  withdrawn 
somewhat,  and  its  direction  slightly  altered.  Independently 
of  any  pathological  obstruction,  it  should  be  remembered  that 
the  bougie  may  catch  in  one  of  the  folds  of  the  rectum,  or 
impinge  upon  the  promontory  of  the  sacrum,  or  be  caught  in 
the  cul-de-sac  of  an  intussusception. 

Injuries  effected  by  the  introduction  of  a  bougie  have  already 
been  indicated  (see  p.  568). 

For  the  kinds  of  bougies  in  use,  and  the  cases  best  suited 
for  their  respective  application,  see  p.  595. 

For  the  method  of  introducing  the  hand  into  the  rectum, 
see  p.  566. 

3.  Internal  proctotomy  resembles  in  all  respects  internal 
cesophagotomy  and  is  employed  as  an  operation  for  the  same 
conditions. 

The  strictures  best  suited  for  the  operation  are  those 
situated  nearer  the  anal  extremity  of  the  gut. 

The  bowel  is  previously  cleansed  as  well  as  the  condition 
will  permit.  An  anaesthetic  is  administered  and  the  patient 
placed  in  the  lithotomy  position.  The  anus  is  forcibly  dilated 
and  the  lower  end  of  the  stricture  exposed  by  a  speculum.  A 
probe-pointed  straight  bistoury  is  then  passed  through  the 
stricture,  guided  either  by  what  is  seen  through  the  speculum 
or  by  the  introduction  of  the  forefinger  of  the  left  hand.  The 
knife  is  then  made  to  cut  through  the  stricture  sufficiently 
deeply  to  reach  the  healthy  tissues  beneath.     In  some  cases 


OPERATIONS  679 

the  one  incision  will  be  sufficient,  in  others  two  or  more  will 
be  required. 

William  Allingham/  who  has  practised  this  operation  in  a 
considerable  number  of  cases,  usually  divides  the  stricture  at 
four  points.  Immediately  after  the  incisions  he  fills  the  bowel 
with  well-oiled  lint  or  wool  for  twenty-four  hours  ;  and  then 
after  its  removal  introduces  a  vulcanite  tube  furnished  with  a 
collar  to  which  tapes  are  attached  to  keep  it  in  the  bowel  and 
prevent  it  slipping  into  the  rectum.  This  is  worn  continu- 
ously for  some  time,  and  only  removed  when  the  bowels  act, 
and  when  the  rectum  is  washed  out  with  some  very  dilute 
Condy's  fluid  or  thymol. 

One  of  the  alleged  objections  to  this  operation  is  the  diffi- 
culty of  incising  the  stricture  with  such  nicety  that  while  the 
incisions  completely  divide  the  cicatricial  tissue  they  do  not 
enter  too  deeply  into  the  healthy  tissues  beneath.  Should 
these  healthy  tissues  be  incised  too  freely,  there  is  the  danger 
of  septic  infection  of  the  wound,  with  consequent  proctitis  or 
periproctitis. 

An  essential  feature  of  the  operation  is  the  maintenance 
of  dilatation.  Unless  tubes  are  constantly  worn  or  introduced 
for  a  prolonged  period  from  time  to  time,  recontraction  will 
take  place,  and  a  renewal  of  all  the  old  troubles  follow. 

4.  External  proctotomy. — This  operation  is  sometimes  spoken 
of  as  linear  or  posterior  proctotomy,  and  is  employed  for 
opening  the  rectum  for  the  removal  of  impacted  foreign  bodies, 
tumours,  or  for  the  division  of  strictures,  innocent  or  malignant. 
It  consists  in  laying  open  the  bowel  completely  from  and  in- 
cluding the  anus,  upwards  and  backwards  towards  the  coccyx. 

The  patient  is  placed  in  the  lithotomy  position,  and  the 
tissues  divided  posteriorly  by  means  of  the  ecraseur,  the 
galvano-cautery,  or  the  knife. 

The  former  two  methods  were  employed  by  Verneuil  with 
the  object  of  better  checking  the  haemorrhage.  The  knife  is, 
however,  now  most  generally  used. 

In  operating  for  stricture  two  methods  of  using  the  knife 
may  be  employed.  In  the  first  the  anus  and  the  part  of  the 
rectum  and  tissues  behind  and  below  the  stricture  are  cut 
through  with  an  ordinary  scalpel.     The  lowest  part  of  the 

'  Diseases  of  the  Ecctuiii,  p.  261. 


680  THE   RECTUM 

stricture  is  thus  fully  exposed,  and  its  complete  division  is 
then  proceeded  with.  In  the  second  method  either  a  sharp- 
pointed  curved  bistoury  is  guided  throufih  the  stricture,  and 
the  whole  tissues  cut  in  the  median  Hne  posteriorly ;  or  an 
ordinary  scalpel  is  used  and  the  same  structures  divided 
from  without. 

In  order  to  check  the  haemorrhage  which  may  follow  the 
wound  should  be  tightly  packed,  the  stuffing  being  removed 
daily  by  degi'ees.  The  advantage  of  this  operation  is  the  com- 
plete drainage  which  it  affords,  and  hence  the  httle  likelihood 
of  those  inflammatory  complications  which  sometimes  arise 
when,  in  the  case  of  stricture,  the  incisions  are  carried  out 
whoUy  within  the  bowel. 

The  operation  and  its  results  have  been  carefulh'  considered 
by  Kelsey  ^  whose  series  of  collected  cases  is  worthy  of  atten- 
tion. 

5.  Proctectomy. — The  operation  implies  partial  or  complete 
removal  of  the  rectum  for  ulceration,  stricture,  or  cancer.  It 
is  performed  either  from  below  through  the  perineum  (perineal) 
or  from  behind  through  the  sacrum  (sacral  or  posterior)  or 
through  the  vagina  (vaginal). 

TMiichever  of  these  three  operations  is  performed,  certain 
preparations  of  the  patient  and  of  the  rectum  are  requisite 
before  commencing  to  excise  the  part.  The  bowels  should  be 
well  cleared  out  by  the  administration  of  a  good  dose  of  castor 
oil  administered  two  days  before  the  operation.  A  second 
dose  should  be  administered  the  morning  before  ;  and  upon 
the  morning  of  the  operation  copious  enemata  of  dilute  Condy's 
fluid  should  be  used.  Eoatier  ^  adopts  a  very  rigid  course. 
The  patient  is  purged  several  times  before  the  day  of  operating 
with  castor  oil.  About  half  a  drachm  of  naphthol  with  an  equal 
quantity  of  salicylate  of  magnesia  is  administered  each  day 
and  the  diet  is  limited  exclusively  to  mhk.  By  this  process 
of  preparation,  it  is  said,  the  stools  become  inodorous  and  re- 
semble those  of  a  child. 

TMiere,  from  the  tightness  of  the  stricture,  or  from  the 
obstructiveness  of  the  growth,  it  is  found  impossible  to  get 
the  bowel  well  emptied  above  the  seat  of  disease,  an  artificial 

'  Diseases  of  tJie  Rectum,  p.  209. 

^  Eeviie  de  Chirurgie,  1889,  vol.  ix.  p.  971. 


OPERATIONS  681 

anus  should  be  made  in  the  groin.  This  preliminary  measure 
is  most  advantageous  when  the  operation  is  to  be  by  the  sacral 
method,  and  is  by  some  advocated  in  all  cases  as  preparatory 
for  it.  It  is  usual  to  make  the  anus  in  the  left  groin,  but  if 
the  meso-sigmoid  is  short,  and  the  amputation  likely  to  be  a 
high  one,  the  first  opening  should  be  closed,  and  a  colonic 
anus  made  in  the  right  groin.  By  so  doing  there  will  be  less 
difficulty  in  pulling  down  the  requisite  amount  of  bowel  for 
fixation  either  in  the  sacral  or  perineal  regions. 

Perineal  proctectomy. — The  term  perineal  is  not  particularly 
apt,  as  the  operation  is  not  strictly  through  the  perineum,  which 
is  situated  mostly  anterior  to  it.  The  term  serves,  however, 
to  distinguish  it  from  the  other  two  regions  from  which  the 
gut  may  be  approached.  The  operation  is  sometimes  spoken 
of  as  Lisfranc's,  inasmuch  as  this  surgeon  was  the  first  to  place 
it  upon  a  practical  basis.     This  was  in  1830. 

The  patient  is  placed  in  the  lithotomy  position.  A  sharp- 
pointed  curved  bistoury  is  introduced  at  the  anus,  guided  by 
the  index  finger  of  the  left  hand.  The  point  is  made  to  trans- 
fix the  bowel  posteriorly  opposite  the  apex  of  the  coccyx  ;  it  is 
then  made  to  cut  its  way  outwards  keeping  strictly  to  the 
middle  Ime.  The  lower  part  of  the  bowel  is  thus  completely 
laid  open.  After  securing  any  bleeding  points,  the  edges  of 
the  wound  are  each  transfixed  by  a  piece  of  silk  of  sufficient 
length  to  admit  of  their  being  held  firmly  apart  while  the 
next  stage  of  the  operation  is  proceeded  with. 

The  next  step  in  the  operation  is  to  commence  a  separation 
of  the  lower  end  of  the  rectum.  If  the  anus  is  to  be  preserved, 
then  an  incision  is  carried  round  the  bowel  at  the  junction  of 
the  mucous  membrane  and  the  skin ;  if  not,  then  a  circular 
incision  is  made  through  the  skin  just  external  to  the  anus, 
and  the  external  sphincter  therefore  removed.  After  this  in- 
cision the  finger  will  best  aid  in  detaching  the  bowel.  In  order 
to  free  it  more  readily,  and  also  for  manipulative  purposes, 
the  lowest  part  of  the  bowel  should  be  secured  by  ring  vulsel- 
lum  forceps  or  preferably  by  a  stout  silk  thread.  Grasping 
either  of  these  with  the  left  hand,  the  operator  can  pull  the 
rectum  to  one  or  the  other  side,  backwards  or  forwards,  and 
so  very  materially  facilitate  its  detachment  either  by  the 
fingers,  blunt  instruments,  or  the  scissors,  from  the  neighbour- 


682  THE  RECTUM 

ing  parts.  Care  must  be  taken  when  sej^arating  in  front 
not  to  injure  or  open  the  vagina  in  the  female,  or  similarly  the 
urethra  and  the  prostate  in  the  male.  The  introduction  of  a 
catheter  into  the  bladder  will  serve  to  indicate  the  position  of 
the  urethra. 

When  the  upper  limit  of  the  diseased  part  is  reached  the 
bowel  is  severed.  This  may  be  effected  either  by  the  ecraseur, 
the  cautery,  or  the  scissors.  Haemorrhage  occurring  during 
the  operation  should  be  checked  by  the  application  of  forci- 
pressure  forceps,  or  small  pressure  pads. 

There  is  little  use  in  attempting  to  bring  the  mucous  mem- 
brane above  down  to  the  skin  and  stitching  it  there,  as  the 
tension  which  necessarily  exists  invariably  causes  the  sutures 
soon  to  cut  through.  The  part  should,  therefore,  be  freely 
irrigated,  dried,  and  dusted  with  iodoform.  A  large-sized 
rubber  tube  should  be  passed  into  the  bowel,  and  the  parts 
around  packed  with  iodoform  gauze.  Opium  should  be  freely 
administered,  in  order  to  bind  the  bowels  for  several  days. 
Later,  dilatation  will  have  to  be  kept  up  by  the  continuous  use 
of  bougies. 

Cripps  ^  uses  a  full-sized  bougie  ly^g-  inch  in  diameter.  It 
is  employed  at  the  end  of  a  fortnight,  and  allowed  to  remain 
in  some  hours  daily  for  a  month.  The  patient  is  then  directed 
to  pass  the  bougie  daily  for  a  year  or  even  longer.  The  ten- 
dency to  contraction  seems  to  gradually  disappear  and  give 
comparatively  little  trouble  after  the  second  year. 

Should  the  peritoneal  cavity  be  opened,  an  attempt  may 
be  made  to  close  it ;  failing  this,  however,  no  harm  is  likely 
to  accrue  if  the  wound  proper  has  been  rendered  carefully 
aseptic. 

In  the  course  of  a  day  or  two,  the  stuffing  should  be  re- 
moved, and  fresh  introduced.  If,  however,  there  has  been 
any  leakage  of  faeces,  or  the  wound  in  any  other  way  appears 
septic,  the  wound  should  not  be  restuffed,  but  irrigated  with 
some  antiseptic  solution  three  times  a  day. 

'  Brit.  Med.  Journ.  1892,  vol.  ii.  p.  1277. 


OPERATIONS  683 

CHAPTEB   LXXXIII 

OPERATIONS  (continued),     sacral  proctectomy 

Sacral  proctectomy. — The  object  of  this  operation  is  to  re- 
move disease  situated  too  high  up  to  be  dealt  with  by  the 
perineal  method. 

The  operation  will  be  best  considered  by  treating  it  in  three 
stages.  (1)  The  incisions  made  for  exposing  the  bowel ;  (2) 
removal  of  the  bowel ;  (3)  the  securing  of  the  upper  segment 
after  amputation.  An  exception  is  made  in  the  case  of 
Kraske,  whose  first  operation,  described  in  full,  was  carried 
out  successfully  in  1885.  It  was  the  pioneer  of  the  class,  and 
although  numerous  modifications  have  been  introduced  since, 
the  name  of  this  surgeon  is  still  retained  and  used  to  express 
amputation  of  the  rectum  from  behind. 

(1)  The  incisions  made  for  exposing  the  rectum. — The  opera- 
tion, as  carried  out  by  Kraske  '  in  his  first  two  successful  cases, 
was  thus  performed  :  The  patient  was  laid  upon  the  right  side  ; 
an  incision  was  made  in  the  middle  line  down  to  the  bone, 
from  the  centre  of  the  sacrum  to  the  anus.  The  skin  and  sub- 
cutaneous tissue  with  the  fibres  of  the  gluteus  maximus  were 
detached  from  the  lower  part  of  the  left  side  of  the  sacrum.  The 
coccyx  was  then  removed.  The  lower  part  of  the  great  sacro- 
sciatic  hgament,  and  the  lesser  ligament  beneath  it,  were  next 
detached  from  the  side  of  the  sacrum.  With  a  gouge  the  lower 
part  of  the  left  side  of  the  sacrum  was  removed,  the  cut  being 
concave,  starting  from  the  margin  of  the  bone  on  a  level  with 
the  lower  border  of  the  third  left  sacral  foramen,  and  including 
within  the  detached  fragment  the  fourth  sacral  foramen  (see 
fig.  117).  After  freeing  the  connective  tissue  and  muscles 
from  the  posterior  wall  of  the  gut,  the  patient  was  placed  in 
the  lithotomy  position,  with  the  pelvis  well  raised.  The  con- 
nections anteriorly  were  then  severed.  As  the  disease  in 
neither  case  involved  the  anal  segment  of  the  gut,  the  healthy 
bowel  below  was  divided  transversely  after  having  been  pre- 
viously split  up  to  within  half  an  inch  of  the  disease.     The 

'  Archivfilr  klin.  Chir.  1886,  Bd.  xxxiii.  p.  563  ;   also  Beilage  zum  Central- 
blattfUr  Chiriirgie,  1885,  No.  21,  p.  75. 


684 


THE   RECTUM 


rectum  above  the  seat  of  disease  was  also  cut  across  with  a 
pair  of  scissors.     The  peritoneal  cavity,  which  had  been  opened 

in  the  process  of  detach- 
ing the  bowel,  was  then 
cleaned  and  dusted  over 
with  iodoform,  and  then 
the  bowel  above  drawn 
down,  and  stitched  for 
two-thirds  of  its  circum- 
ference with  the  lower 
anal  segment.  A  drain- 
age tube  was  passed  into 
the  peritoneal  cavity  on 
the  left  side.  The  bowel 
was  also  tightly  stuffed 
in  order  to  press  the  peri- 
toneal surfaces  together. 
The  wound  was  finally 
tamponed  with  iodoform 
gauze. 

Notwithstanding  the 
success  which  attended 
these  two  operations,  sur- 
geons soon  began  to  learn 
by  experience  that  various  improvements  were  needed  if  the 
best  results  were  to  be  obtained.  Hence  numerous  modifica- 
tions were  rapidly  introduced,  and  concerned  the  mode  of 
approach  to  the  rectum,  its  removal,  and  the  treatment  of  the 
parts  after  removal. 

The  particular  points  which  these  various  modifications 
aimed  at  were :  to  retain  a  proper  support  to  the  bowel  and 
the  pelvic  contents  :  to  avoid  any  injury  to  the  nerves  supply- 
ing the  bladder  and  the  levator  ani :  to  avoid  interference  with 
the  blood  supply  of  the  lower  part  of  the  bowel :  to  lessen  the 
haemorrhage ;  and  to  obtain  for  the  patient  some  control  over 
the  contents  of  the  bowel. 

The  attempt  to  retain  the  normal  osteo-ligamentous  sup- 
port to  the  floor  of  the  pelvis  led  to  the  introduction  of  the 
formation  of  osteo-integumental  flaps,  that  is  to  say,  flaps 
composed  of  bone  and   the  superimposed  soft  tissues,  which, 


Fig.  117 Showing  the  amount  of  Bone 

Eemoved  by  Diffekent  Operators 

ab,  Kraske  ;  ac,  Hocheiiegg  ;  ad,  Kraske  for  extreme 
cases.    (Hochenegg) 


OPERATIONS  685 

after  being  temporarily  turned  aside  for  the  excision  of  the 
diseased  part,  are  replaced  and  secured  in  their  original  position. 

Associated  witli  this  method  of  operating  are  the  names 
of  many  German  surgeons — Heineke,  Kocher,  Levy,  Hegar, 
Rehn,  Eydygier,  Borelius  and  others. 

Some  of  these  methods  may  be  shortly  referred  to. 

Hcinekes  method.^ — Heineke  led  the  way  in  making 
the  first  modification  of  this  nature  in  Kraske's  operation. 
It  was  published  in  1888,  the  year  following  the  record  of 
Kraske's  original  operation. 

The  incision  was  carried  through  the  sphincter,  along  the 
middle  line  to  the  top  of  the  coccyx,  so  that  the  lower  part  of 
the  bowel  was  first  opened  and  dealt  with  as  further  described. 
The  incision  was  then  continued  along  the  median  line  of  the 
sacrum,  the  bone  sawn  through  in  the  same  line  as  far  up 
as  the  lower  level  of  the  third  sacral  foramina.  Two  cuts  were 
then  carried  transversely  outwards  on  each  side,  and  the 
triangular  osteo-integumental  flaps  thus  made  forcibly  turned 
outwards,  exposing  freely  thereby  the  posterior  rectal  region. 

Koclier's  method  ^  resembles,  in  the  shape  and  consti- 
tuents of  its  flaps,  that  of  Heineke.  It  differs,  however,  in 
the  manner  in  which  the  flaps  are  cut.  Kocher,  after  mak- 
ing his  median  posterior  incision,  detaches  the  soft  parts 
laterally  as  far  as  the  posterior  sacral  foramina.  A  thin 
strip  of  bone  is  then  chiselled  oat  so  as  to  open  the  spinal 
canal  and  expose  the  sacral  nerves.  These — the  thu'd  and 
fourth — are  then  carefully  held  aside  while  the  sacrum  is 
sawn  across  just  below  the  third  sacral  foramina. 

Levifs  method.'-^ — In  this  a  horizontal  and  not  a  median 
skin  incision  is  made.  An  incision  skin  and  fascia  deep  is 
carried  across  the  sacrum  about  a  finger's  breadth  above  the 
cornua  of  the  coccyx.  Its  two  lateral  extremities  pass  out- 
wards and  downwards  so  as  to  slope  in  a  direction  parallel  to 
the  fibres  of  the  gluteus  maximus.  Each  terminates  laterally 
about  two  inches  from  the  tuber  ischii.  The  fourth  sacral 
foramen  is  identified.  The  fibres  of  the  gluteus  maximus 
are  separated  on  each  side  until  the  sacro-sciatic  ligaments 

'  Centralblatf  fiir  Chiriirgie,  1888,  No,  52,  p.  962. 

-  McCosh,  Neiv  York  Med.  Joiirn.  1892,  vol.  Ivi.  p.  256. 

^  Berliner  kiln.  Wochcnschrift,  1893,  No.  13,  p.  304. 


686  TPIE   RECTUM 

are  laid  bare.  These  ligaments  are  then  carefully  divided 
upon  a  director  (to  avoid  injuring  the  pudic  vessels  and  nerve) 
in  the  line  of  the  original  incision  until  the  lateral  margin 
of  the  bone  is  reached.  This  division  of  the  ligaments  only, 
therefore,  detaches  a  portion  of  them  from  the  bone ;  that 
which  is  attached  to  the  lower  part  of  the  sacrum  and  the 
coccyx  remains  intact.  The  parts  in  front  of  the  sacrum  are 
separated  along  the  same  horizontal  line  sufficiently  to  admit 
of  the  chain-saw  being  introduced.  By  this  means  the 
sacrum  is  sawn  across.  The  broad  osteo-integumental  flap 
is  then  forcibly  pulled  backwards  towards  the  anus,  and  the 
posterior  rectal  region  exposed. 

Hegars  method.^ — In  this  operation  the  osteo-integu- 
mental flap  is  the  opposite  of  that  of  Levy's,  being  turned  up 
instead  of  down.  Two  divergent  incisions  are  made  from  the 
anus  to  the  side  of  the  sacrum  opposite  the  lower  level  of  the 
third  sacral  foramina.  The  parts  are  separated  laterally  until 
the  chain-saw  can  be  introduced,  and  the  bone  cut  through 
subcutaneously.  The  flap  is  then  forcibly  drawn  upwards, 
and  the  posterior  rectal  region  exposed. 

Rehns  method. — In  1890  Kehn  ^  described,  at  the  nine- 
teenth Congress  of  German  Surgeons,  cases  successfully 
treated  by  a  modification  of  Kraske's  operation ;  and  in  1894 
Eydygier  ^  followed  with  the  description  of  an  operation  pre- 
cisely similar.  Of  all  the  osteo-plastic  methods  at  present 
devised,  this  appears  to  have  superseded  all  others,  and  re- 
ceived most  practical  recognition.  It  is  sometimes,  and 
perhaps  most  appropriately,  designated  the  Rehn-Uydygier 
method. 

It  is  thus  performed : — An  incision  is  commenced  close 
behind  the  posterior  superior  spine  of  the  ilium,  and  continued 
along  the  left  of  the  sacrum  about  half  an  inch  from  the 
margin  of  the  bone  ;  when  it  reaches  the  apex  of  the  coccyx 
it  is  prolonged  in  the  median  line,  as  far  as  is  considered 
necessary.  At  the  upper  end  of  the  incision,  the  margin  of 
the  sacrum  is  then  exposed,  and  the  greater  and  lesser  sacro- 
sciatic  ligaments  divided.     The  anterior  part  of  the  sacrum  is 

'  Gerster,  Annals  of  Siurgery,  1895,  vol.  xxii.  p.  489. 

''■  Beilage  zum  Cenfralblatt  fiir  Chirurgie,  1890,  No.  25,  p.  65. 

'  Kelsev,  Anyiual  of  the  Universal  Medical  Sciences,  1894,  vol.  iii.  E — 11. 


OPERATIONS  ■  687 

next  carefully  denuded  of  its  soft  parts ;  after  which  a  trans- 
verse incision  is  carried  across  the  sacrum  from  the  original 
incision,  at  a  point  about  two  inches  from  the  junction  of  the 
sacrum  and  the  coccyx,  that  is  to  say,  just  below  the  third 
sacral  foramina.  The  sacrum  is  chiselled  through  at  the  same 
level,  and  the  large  triangular  flap  thus  made  drawn  over  to 
the  right  side. 

After  removal  of  the  disease  the  osteo-integumental  flap 
is  replaced,  but  whether  or  not  it  should  be  stitched  into 
position  will  depend  upon  the  amount  of  bowel  which  has 
been  removed  ;  whether,  in  other  words,  the  bowel  has  been 
sutured  to  the  anus  or  anal  segment,  and  it  is  considered 
possible  no  leakage  will  take  place,  or  whether  no  such  union 
has  been  attempted  between  the  divided  extremities.  In  the 
former  case  it  may  be  secured,  in  the  latter  it  should  not,  but 
the  cavity  should  be  stuffed  with  iodoform  gauze. 

Borelius'  method} — The  patient  is  placed  upon  the  right 
side,  with  the  knees  drawn  up  and  the  pelvis  raised.  The 
skin  incision  is  carried  from  the  tip  of  the  coccyx  upwards  to 
a  little  above  the  middle  of  the  sacrum.  Below,  the  skin  in- 
cision follows  the  lower  border  of  the  right  gluteus  muscle. 
The  right  skin  flap  with  some  of  the  tendinous  attachments 
of  the  gluteus  are  detached  from  the  bone  and  held  aside. 
The  left  skin  edge  is  also  sufficiently  loosened  to  allow  of  the 
sacrum  being  chiselled  through  obliquely  from  below  the  third 
left  sacral  foramen  to  below  the  right  fourth.  This  bone  flap 
when  sufficiently  freed  is  drawn  over  to  the  left  until  after 
the  operation  upon  the  bowel  is  completed,  when  it  is  re- 
placed. 

These  six  methods  of  forming  osteo-integumental  flaps  are 
not  applicable  when  a  sacral  anus  has  to  be  made.  Their 
great  advantage  lies  in  the  support  which  is  given  to  the 
bowel  and  the  intrapelvic  contents  when  it  has  been  found 
possible  to  accurately  unite  the  divided  extremities  of  the 
former,  or  bring  the  upper  segment  of  the  gut  down  to  the 
perineum  without  much  traction. 

Another  method  of  maintaining  good  sujDport  to  the  bowel 
has  been  devised  by  Zuckerkandl  and  by  Wolfler.  It  is  spoken 
of  as  the  'parasacral  method,''  and  consists  in  dividing  the 
'  McCosh,  New  York  Med.  Joxmi.  1892,  vol.  hi.  p.  257. 


688  THE    RECTUM 

structures  attached  to  the  left  side  (Zuckerkandl)  or  the  right 
side  (Wolfler)  of  the  sacrum,  that  bone  remaining  intact. 
Wolfler  in  addition  takes  away  the  coccyx.  Both  surgeons 
claim  to  have  operated  with  good  results.  The  space  which 
the  incision  allows  is  somewhat  limited,  hence  removal  of 
extensive  diseases  is  apt  to  be  difficult,  if  not  impossible. 

(2)  Removal  of  the  rectum..— By  whatever  method  the  bowel 
is  approached  or  exposed,  the  next  point  for  consideration  is 
the  removal  of  the  diseased  part. 

The  freeing  of  the  gut  from  its  connection  should  be  either 
with  the  finger  or  with  some  blunt  instrument,  and  where 
divisions  are  needed  the  scissors  should  be  used.  Bleeding 
poiuts  should  be  at  once  caught  up  with  catch  forceps,  and  all 
parenchymatous  oozing  checked  by  stuffing.  If  the  peritoneal 
cavity  is  opened,  it  should  be  carefully  protected  while  the 
bowel  is  removed.  This  latter  may  be  effected  either  by  the 
scissors,  the  cautery,  or  the  ecraseur.  When  it  is  impossible 
to  tell  by  external  examination  the  height  to  which  the  disease 
has  extended,  the  bowel  should  be  opened  and  the  finger  intro- 
duced to  determine  the  proper  point  for  making  the  division. 
To  prevent  the  possibility  of  the  upper  segment  slipping  out 
of  reach  in  cases  of  high  amputation,  care  should  be  taken  to 
properly  secure  it  with  forceps  before  severance  is  completed. 

After  the  bowel  has  been  excised  the  wound  should  be 
carefuUy  cleansed,  and  then  the  opening  in  the  peritoneal 
cavity  sought  for.  Although  but  little  harm  has  in  many 
cases  followed  leaving  the  peritoneal  opening  untouched,  the 
general  opinion  is  that  if  closure  is  possible  it  should  be 
effected. 

The  next  step  in  the  operation  is  to  bring  the  gut  down,  and 
here  I  quote  from  the  directions  which  are  well  expressed  by 
Gerster '  :  '  Where  high  amputation  is  to  be  performed,  the 
surgeon  must  try  sedulously  to  preserve  the  nutrient  vt  ssels 
of  the  mesentery,  otherwise  the  entire  rectal  stump  may 
mortify.  This  will  be  found  most  difficult  in  that  part  of  the 
rectum  which  adjoins  the  flexure.  Lateral  mcisions  through 
the  peritoneal  attachments  are  permissible,  but  cutting  into 
the  mesenteric  line  itself  will  certainly  be  followed  by  disaster. 
Adequate  lateral  incisions  wiU  permit  the  surgeon  to  peel  up 

'  Annals  of  Surgery,  1895,  vol.  xxii.  p.  494. 


OPERATIONS  689 

the  gut  from  the  sacrum  by  the  gentle  use  of  the  finger-tip. 
The  higher  this  detachment  of  the  gut  is  carried  up,  the  less 
tension  will  have  to  be  encountered  in  drawing  down  and 
attaching  the  stump  to  the  upper  angle  of  the  external  incision, 
especially  where  portions  of  the  sacrum  have  been  removed. 
A  few  stout  silk  sutures  passed  through  the  entire  thickness 
of  the  gut  laterally  will  serve  amply  to  anchor  the  gut  to  the 
skin,  the  rest  of  the  wound  remaining  open.' 

(3)  The  securinj  of  the  upper  segment  after  amputation. — The 
ideal  result  is  obtained  when  it  is  possible  to  retain  normal 
control  through  the  external  sphincter.  Retention  of  the  ex- 
ternal sphincter  is  of  course  only  possible  in  cases  where 
the  anal  portion  of  the  gut  is  not  implicated  ;  and  further  its 
future  use  as  a  sphincter  is  only  possible  when  the  upper 
segment  can  be  brought  down  without  tension  to  be  attached 
to  the  anal  portion. 

Where  such  union  of  the  two  divided  segments  seems 
feasible,  it  may  be  attempted  by  one  of  two  methods— either 
by  circular  suture,  or  by  some  mechanical  means,  as  by 
Murphy's  button. 

In  most  of  the  earlier  cases  of  circular  suture,  some  of  the 
stitches  gave  way  and  fistula  resulted.  Kuster  ^  observes  that 
in  every  case  in  which  he  stitched  the  bowel  completely  round, 
the  stitches  cut  out  posteriorly  and  a  fistula  resulted.  In  some 
of  these  the  systematic  use  of  a  rectal  bougie  caused  the  fistula 
to  close,  but  in  others  its  passage  had  no  effect.  Czerny  ^ 
never  obtained  a  good  sphincter  action  after  suture  without 
splitting  the  sphincter  first.  Schede,  Kammerer,  and  others 
do  not  attempt  union  by  suture  without  making  a  preliminary 
inguinal  anus. 

The  union  of  the  divided  ends  by  a  Murphy's  button  has 
been  successful.  Marcy  ^  reports  having  excised  four  inches 
of  the  rectum  by  a  modified  Kraske  and  united  the  ends  b}^  a 
large-sized  button.  The  button,  which  caused  some  irritation 
of  the  bladder,  was  passed  on  the  twelfth  day;  a  fistulous 
opening,  however,  formed  posteriorly  at  the  site  of  union. 

In  order  to  get  over  the  difficulty  caused  by  the  sutures 

'  Berliner  klin.  Wochenschrift,  1889,  vol.xxvi.  p.  193. 

2  Beitrage  ziir  klin.  Chir.  1892,  Bd.  ix.  p.  409. 

'  Boston  Med.  and  Surg.  Journ.  1893,  vol.  cxxix,  p.  561, 

Y  Y 


690  THE    RECTUM 

giving  along  the  line  of  union  of  the  two  united  segments, 
Hochenegg  ^  proposed  to  invaginate  the  stump  into  the  lower 
segment  of  the  gut,  drawing  it  out  through  the  anus  and 
attaching  it  to  the  skin ;  and  in  order  to  ensure  better  union 
between  the  opposing  surfaces,  the  epithelial  lining  of  the  anal 
ring  within  the  sphincter  was  to  be  removed. 

Another  suggestion  to  overcome  the  difficulty  in  bringing 
the  upper  segment  down  to  the  normal  position,  when,  by  doing 
so,  too  much  tension  would  be  caused,  has  been  made  by 
Lange,^  who  successfully  acted  upon  it  in  two  cases.  An  in- 
cision was  made  from  one  tuber  ischii  across  the  perineum  in 
front  of  the  sphincter  to  the  other.  The  incision  was  made 
deep  enough  to  allow  of  pushing  the  whole  muscular  apparatus 
of  the  anus  with  the  anal  portion  of  the  gut  upwards.  Thus 
fully  two  or  three  inches  was  gained,  and  exact  union  of  the 
gut  margins  with  suture  achieved.  Two  years  after  the  per- 
formance of  this  operation  upon  two  men,  both  were  reported 
in  good  condition.  In  both  instances  solid  fseces  could  be 
held,  and  there  was  a  decided  sphincter  action,  not  energetic 
enough,  however,  to  restrain  liquid  fseces. 

When  for  any  reason  it  is  not  possible  to  make  use  of  the 
normal  sphincter,  two  methods  of  obtaining  an  adventitious 
sphincter  action  have  been  devised. 

Willems  ^  proposes  for  a  sphincter  an  opening  through 
the  gluteus  maximus.  A  skin  incision  about  two  to  two  and 
a  half  inches  long  is  carried  obliquely  downwards  and  out- 
wards above  the  tuber  ischii.  The  incision  runs  parallel  to 
the  fibres  of  the  gluteus  maximus,  the  fibres  of  which  are 
then  separated  by  the  forceps  to  the  breadth  of  the  finger. 
Through  this  opening  the  stump  of  the  bowel  is  pulled  and 
stitched  to  the  skin.  When  the  amputation  is  higher  up  it  is 
proposed  to  make  the  opening  through  the  gluteus  correspond- 
ingly higher. 

In  the  following  year  Witzel  ^  described  a  similar  method 
of  obtaining  a  sphincter,  and  designated  the  artificial  anus 
*  rectostomia  glutealis.'     A  little  later  Eydygier  ^  appears  to 

'  Gerster,  Annals  of  Surgery,  1895,  vol.  xxii.  p.  495. 

2  Neiv  York  Med.  Journ.  1891,  vol.  liii.  p.  309. 

^  Centralblait  filr  Chirurgie,  1893,  vol.  xx.  p.  401. 

^  Ibid.  1894,  No.  40,  p.  938.  ^  j^.^j,  ^q_  45^  p.  io83. 


OPERATIONS  G91 

have  hit  upon  the  same  plan,  which  is  illustrated  by  a 
drawing. 

Gersuny '  records  two  successful  results  by  an  ingenious 
method  of  torsion.  After  removal  of  the  diseased  portion,  the 
upper  segment  is  pulled  down,  and  by  two  pairs  of  forceps 
placed  on  opposite  sides  the  bowel  is  twisted  until  the  finger 
feels  some  resistance  when  introduced  and  pushed  up.  It  is 
then  stitched  to  the  skin  margin.  In  both  the  cases  so  treated 
there  was  power  to  retain  fseces. 

If  no  attempt  is  to  be  made  to  obtain  any  sphincter  action, 
then  the  bowel  must  be  either  left  in  position  with  the  intro- 
duction of  a  tube  from  the  lowest  part  of  the  wound  into  it, 
or  it  must  be  secured  to  the  skin  of  the  wound  at  such  a  point  as 
allows  of  little  or  no  tension  ;  in  other  words,  a  sacral  anus  must 
be  formed.  In  either  of  these  methods  the  wound  cavity  must 
be  loosely  stuffed  with  iodoform  gauze  and  left  freely  open. 

After  treatment. — Every  effort  must  be  made  to  keep  the 
bowels  confined  for  a  few  days,  by  the  administration  of 
opium,  and  a  milk  diet.  When  the  metal  button  is  used,  it 
is  advised  by  Murphy  that  an  early  and  free  use  of  laxatives 
be  employed,  so  that  the  button  may  not  become  dammed  up 
with  solid  faeces. 

When  a  wound  has  been  stuffed,  the  tissue  should  be  re- 
moved after  forty-eight  hours,  and  earlier  if  there  is  any  fear 
of  fecal  leakage,  or  any  symptoms  of  sepsis.  It  may  be 
restuffed,  or  freely  and  frequently  irrigated,  according  to  cir- 
cumstances. 

When  once  the  wound  is  freely  granulating,  and  there  is 
no  indication  of  inflammation,  the  patient  may  be  allowed  to 
rise,  and  sit  or  even  walk.  The  earlier  this  freedom  can  be 
permitted,  the  better. 

In  cases  of  sacral  anus,  Hochenegg  has  devised  a  pad 
which  is  secured  by  a  hinge  to  a  belly  band.  It  is  kept  firmly 
applied  to  the  orifice  by  a  strap  passing  from  the  front  down 
between  the  legs,  across  the  perineum  and  up  behind.  Accord- 
ing to  Thorndike,^  who  figures  the  apparatus,  it  does  its  work 
efficiently  and  with  comfort  to  the  patients. 

Vaginal  proctectomy. — Little  has  been  done  with  regard  to 

'  Centralhlatt  fur  Chirurgic,  1893,  vol.  xx.  p.  553. 

^  Boston  Med.  and  Surg.  Journ.  1891,  vol.  cxxiv.  p.  456. 

Y    Y    2 


692  THE    RECTUM 

approaching  the  rectum  through  the  vagina.  In  1895  Eehn 
described  an  operation  which  he  had  performed  on  an  old 
woman  aged  81  years ;  but  in  a  footnote  appended  to  the 
description  Eichter  points  out  that  Campenon  had  already 
successfully  performed  the  operation. 

The  mode  of  operating  is  thus  briefly  described  by  Eehn.^ 
The  rectum  is  tamponed,  and  the  vagina  thoroughly  disinfected. 
A  shallow  median  incision  is  carefully  made  in  the  posterior 
wall  of  the  vagina,  reaching  to  the  sphincter  ani.  The  rectum 
is  separated  first  at  the  anal  extremity,  and  then  pulled  up  by 
an  assistant  towards  the  symphysis,  by  which  means  the 
requisite  length  of  the  gut  is  detached. 

It  remains  to  refer  briefly  to  three  other  methods  of  deal- 
ing with  disease  situated  high  up  in  the  rectum,  or  of  a 
character  too  fixed  to  remove. 

(1)  Removal  hy  McmnselVs  method  (see  page  532).— The 
abdomen  is  opened,  an  incision  made  in  the  sigmoid,  and  the 
diseased  segment  invaginated  into  the  latter,  brought  out  of 
the  intestinal  orifice  and  removed,  union  of  the  gut  ends  being 
then  effected  as  in  the  same  operation  for  intussusception. 
The  operation  was  successfully  carried  out  in  a  case  reported 
by  Hartley  .2 

(2)  Uhlmann  ^  proposes  to  expose  the  rectum  by  an  ordinary 
Kraske,  bring  down  a  piece  of  intestine  and  suture  it  into  the 
rectum  below  the  seat  of  disease.  The  proposed  operation  is 
termed  '  Colo-rectostomy.' 

(3)  Bacon  '*  suggests  opening  the  abdomen  and  stitching  a 
coil  of  intestine  to  the  rectum.  When  adhesions  have  suffi- 
ciently formed,  an  opening  is  made  into  the  bowel  from  the 
rectum,  below  the  disease  in  the  latter.  The  method  is  well 
described  by  illustrations. 

6.  Proctorrhaphy. — The  term  is  used  to  indicate  suturing 
the  ends  of  the  rectum  together  after  excision.  If,  however, 
an  endeavour  is  to  be  made  to  acquire  some  uniformity  in  the 
terminology  of  operations  upon  the  alimentary  canal,  the 
name  should  strictly  apply  to  Lange's  operation  for  prolapse 

'  Centralblatt  fur  Chirurgie,  1895,  No.  10,  p.  243. 

2  Neio  Ycrk  Med.  Joiirn.  1892,  vol.  Ivi.  p.  464. 

*  Annual  of  the  Universal  Medical  Sciences,  1890,  vol.  iii.  D— 35. 

^  Ihid.  1895,  vol.  iii.  D- 11. 


IlECTAL    AUMEXTATION  tm 

of  the  rectum  (see  page  652).  The  iDrolapsed  and  enlarged 
bowel  is  narrowed  in  its  calibre,  by  inserting  two  rows  of 
buried  sutures,  which  have  the  effect  of  doubling  in  a  longi- 
tudinal fold. 

7.  Proctopexy. — An  operation  performed  for  fixing  the 
rectum  in  cases  of  prolapse.  (See  Verneuil's  operation,  page 
649.) 

8.  Proctoplasty. — The  term  is  applied  to  the  various  opera- 
tions employed  to  open  up  and  transplant  into  the  perineum 
the  rectum  in  cases  of  imperforate  anus  (see  page  665).  In 
view  of  the  specific  application  of  the  afhx  in  the  case  of  the 
stomach  and  the  intestine,  it  would  be  wiser  to  abolish  the 
use  of  the  term  here. 

9.  Rectal  Electrolysis. — Used  for  the  treatment  of  stricture 
of  the  rectum.     (See  page  599.) 

10.  Rectal  Cauterisation. — Used  for  the  treatment  of  pro- 
lapse.    (See  Van  Buren's  operation,  page  643.) 


CHAPTER   LXXXIV 

RECTAL    ADMINISTRATIONS 


Nutritive  and  therapeut'c  enemata. — The  importance  of 
utilising  the  absorptive  powers  of  the  mucous  membrane  of 
the  rectum,  in  the  surgery  of  the  alimentary  canal,  is  so  great, 
that  a  separate  though  brief  reference  to  the  subject  seems 
a  fitting  conclusion  to  the  present  work. 

It  may  be  considered  in  two  aspects,  that  of  alimenta- 
tion, and  that  of  medication. 

Alimentation. — The  administration  of  food  by  the  rectum 
is  of  importance  in  all  cases  where  its  introduction  into  the 
stomach  is  impossible,  or  fraught  with  risks  of  injury  to  parts 
which  have  been  operated  upon. 

Prior  to  giving  the  enema,  an  ordinary  copious  injection  of 
warm  water  should  be  employed,  in  order  to  empty  the  part 
and  cleanse  it  (see  page  677).  The  patient  should  lie  either 
on  the  back  or  the  side,  and  remain  in  the  recumbent  position 
for  some  time  after  the  administration. 


694  THE    RECTUM 

For  introducing  the  aliment,  either  a  syringe  or  a  filler  or 
funnel  attached  to  an  india-rubber  tube  may  be  used.  A 
rectal  tube  of  at  least  six  inches  in  length  should  be  con- 
nected with  the  india-rubber  tube  or  the  nozzle  of  the  syringe, 
and  introduced  as  far  up  the  bowel  as  possible.  This  high 
introduction  of  the  food  is  of  considerable  importance,  as 
bringing  it  into  relation  with  a  larger  absorptive  surface,  and 
also  rendering  it  possible  for  the  material  to  find  its  way  into 
the  colon. 

No  sudden  or  great  force  should  be  used  in  injecting  the 
aliment.  If  a  filler  and  tube  is  used,  the  former  should  be 
held  about  two  feet  above  the  bed,  and  the  material  allowed 
to  gravitate  slowly  into  the  bowel. 

The  quantity  administered  should  be  from  two  to  six 
ounces,  and  warmed  to  about  the  temperature  of  the  body. 
From  two  to  four  enemata  may  be  given  daily,  the  number 
varying  with  the  quantity  and  the  quality  of  the  nutrient  used  ; 
and  if  the  bowel  does  not  empty  itself  naturally  within  forty- 
eight  hours,  a  copious  water  injection  should  be  given  before 
repeating  the  enema.  It  has  been  shown  that  the  ingredients 
most  readily  absorbed  are  such  as  can  be  held  in  solution  ; 
hence  albumen  as  such  is  not  taken  up,  and  must  be 
peptonised. 

The  following  are  good  formulae  for  rectal  alimentation 
taken  from  Eugene  Forster's  article  in  the  *  Reference  Hand- 
book of  the  Medical  Sciences.'  ^ 

Leuhe's  j)ancreatic  meat  emulsion. — '  Take  about  five  ounces 
of  finely  scraped  meat,  chop  it  still  finer,  and  add  to  it  one 
ounce  and  a  half  of  finely  chopped  pancreas  free  from  fat, 
then  add  about  three  ounces  of  lukewarm  water,  and  stir 
to  the  consistence  of  a  thick  pulp.'  This  constitutes  the 
quantity  for  a  single  injection. 

Mayet's  ^jreparation. — '  Take  of  fresh  pancreas  of  the  ox 
from  150  to  200  grammes,  and  of  lean  meat  400  to  500 
grammes.  Bruise  the  pancreas  in  a  mortar  with  tepid  water 
at  a  temperature  of  37°  C,  and  strain  through  a  cloth.  Chop 
the  meat  and  mix  it  thoroughly  with  the  fluid  which  has  thus 
been  strained,  after  separating  all  the  fat  and  tendinous 
portions.     Add   the   yolk  of  one    egg.      Let  stand   for   two 

'  Vol.  ii.  p.  693. 


IIECTAL    ALIMENTATION  G'J5 

hours,  and  administer  at  the  same  temperature'  The 
quantity  made  is  supposed  to  be  sufficient  for  twenty-four 
liours'  nourishment,  and  should  be  administered  in  tvvo 
doses. 

Ttennie's  formula. — *  To  a  bowl  of  good  beef  tea  add  half 
a  pound  of  lean  raw  beef  steak  pulled  into  shreds.  At  99"  F. 
add  one  drachm  of  fresh  pepsin  and  half  a  drachm  of  dilute 
hydrochloric  acid.  Place  the  mixture  before  the  fire  and  let 
it  remain  for  four  hours,  stirring  frequently.  The  heat  must 
not  be  too  great,  or  the  artificial  digestive  process  will  be 
stopped  altogether.' 

The  use  of  blood  as  a  nutrient  enema  is  highly  recom- 
mended by  Sansom,'  who  thus  described  its  preparation  and 
administration  : 

*  Ox  blood  is  usually  employed,  but  sheep's  blood  may  be 
used.  It  is  necessary  that  it  be  defibrinated  the  moment  it 
is  drawn.  Butchers  understand  this  process,  and  will  supply 
what  is  called  "whipped"  or  "stirred"  blood.  It  is,  of 
course,  required  that  the  blood  be  fresh,  that  it  be  not  kept 
more  than  a  single  day  (a  grain  or  a  grain  and  a  half  of 
chloral  hydrate  to  each  ounce  of  blood  serves  to  avert 
decomposition  and  prevent  any  offensive  odour  in  the  dejec- 
tion). In  urgent  cases  where  there  is  no  stomach  digestion 
two  or  three  ounces  of  blood  may  be  injected  into  the 
rectum  every  two  or  three  hours  ;  the  fluid  may  be  warmed 
by  placing  the  containing  vessel  in  hot  water,  but  it  is  often 
borne  equally  well  when  cold.' 

In  recent  years  much  has  been  done  to  simplify  the 
process  of  preparing  food,  but  there  are  those  who  still  prefer 
to  use  the  entirely  fresh  and  recently  prepared  ingredients 
rather  than  any  of  the  condensed  and  more  or  less  artificial 
preparations  now  abundantly  to  be  obtained  in  the  market. 
Many  of  the  latter,  however,  have  been  shown  experimentally 
to  be  capable  of  sustaining  life  for  comparatively  prolonged 
periods  and  fulfilling  therefore  all  the  requirements  of  rectal 
alimentation. 

Some  of  these  ready-made  preparations  are  practically 
foods  in  themselves,  while  others  are  intended  to  be  added 

'  Lancet,  1801,  vol.  i.  p.  322. 


696  THE    RECTUM 

to  certain  quantities  of  aliment  for  the  purpose  of  digesting 
them. 

The  following  are  some  of  the  preparations  met  with  in 
commerce.  As  full  instructions  accompany  each  substance, 
there  is  no  need  to  introduce  any  particulars  here. 

Pepsin  (B.P.)  ;  Pig's  Pepsin  ;  Saccharated  Pepsin  ; 
Armour's  Lactated  Pepsin ;  Pure  Pancreatin ;  Liquor  Pan- 
creaticus  (Benger) ;  Beef  Peptonoids  (Carnrick  and  Co.)  in 
]powders ;  Liquid  Peptonoids  ;  Zymine  Peptonising  Powders 
(Fairchild)  ;  Zyminised  (Peptonised)  Suppositories  (milk)  ; 
Zyminised  (Peptonised)  Suppositories  (beef). 

Forster  speaks  highly  of  the  following  simple  nutrient 
enema : 

Carnrick's  Beef  Peptonoids  one  to  four  drachms,  milk, 
beef  tea  or  rice  water,  four  to  six  ounces  given  twice  daily. 

In  the  use  of  enemata  it  is  advisable  not  to  continue  too 
long  with  one  particular  kind,  but  rather  to  employ  every 
now  and  again  one  containing  different  ingredients.  If  the 
rectum  becomes  intolerant  or  irritable,  a  few  drops  of 
tinctura  opii  should  be  added  to  the  enema.  When  stimu- 
lants appear  needed,  half  an  ounce  or  so  of  brandy  may  be 
mixed  in.     Ewald  prefers  adding  red  wine  to  each  enema. 

The  absorptive  power  of  the  rectum  for  fluids  has  led  to 
its  being  made  use  of  as  a  means  of  getting  water  into  the 
system  when  its  administration  in  large  quantities  by  the 
mouth  might  derange  the  stomach.  Thus  the  injection  of 
considerable  quantities  of  warm  water  has  proved  to  be  of 
great  service  in  cases  where  much  blood  has  been  lost,  and  in 
which  shock  is  a  ^Drominent  symptom.  As  thus  given  it 
is  supposed  to  act  in  the  same  way  as  when  normal  saline 
solution  is  used  for  intravenous  injection.  In  cases  of 
excessive  thirst  from  fever,  and  after  certain  abdominal 
operations,  warm  water  given  ^^e?"  rectum  has  often  a  very 
beneficial  effect  in  allaying  this  troublesome  and  trying 
symptom. 

Therapeutics. — Drugs  are  introduced  into  the  rectum  for  the 
purpose  of  producing  either  local  or  general  effects.  In  form 
they  are  either  fluid  or  solid,  in  the  latter  case  they  constitute 
the  suppositoria. 

It  is  usual  to  classify  enemata  according  to  their  action  ; 


RECTAL    ALLMENTATION  697 

thus  there  are  purgative,  anthehnintic,  astringent,  and 
sedative.  Others  are  used  by  the  physician,  but  these  com- 
prise those  mostly  in  use  in  surgery. 

Purgative  enemata. — The  mechanical  effect  of  large  quanti- 
ties of  fluid  in  inducing  peristaltic  action  of  the  bowel  has 
already  been  referred  to  (see  page  677).  It  is  possible,  how- 
ever, to  bring  about  the  desired  effect  by  using  a  less  quantity 
of  water  and  adding  to  it  some  purgative  drug.  Thus  castor 
oil  or  turpentine,  an  ounce  of  each,  may  be  added  to  and  well 
shaken  up  with  six  to  ten  ounces  of  thin  gruel ;  or  a  solution 
can  be  made  containing  sulphate  of  magnesia.  An  enema  of 
aloes  consists  of  aloes  two  scruples,  carbonate  of  potash  fifteen 
grains,  and  barley  water  half  a  pint ;  or  one  containing  colo- 
cynth  consists  of  extract  of  colocynth  half  a  drachm,  soft  soap 
one  ounce,  and  water  a  piiit ;  mix  and  rub  together. 

Glycerine  is  now  much  used,  and  is  sometimes  very 
powerful  in  its  action,  as  was  once  observed  by  myself  in  the 
case  of  a  patient  who  had  been  operated  upon  for  haemorrhoids 
some  days  previously.  It  caused  much  straining  and  very 
copious  haemorrhage.  From  one  to  two  drachms  are  injected 
by  a  suitable  syringe,  and  usually  in  from  five  to  thirty  minutes 
action  of  the  bowels  will  follow.  Glycerine  suppositories  are 
now  made  containing  in  some  of  the  forms  95  per  cent,  of 
glycerine.  Their  action  is  stated  to  be  attended  with  less 
spasm  than  when  pure  glycerine  is  injected. 

Anthelmintic  enemata. — Thread  worms  and  round  worms 
are  both  met  with  in  the  rectum,  the  former  more  frequently. 
Their  presence  in  children  is  not  unfrequently  the  cause  of 
prolapse.  Strong  solutions  of  salt  and  water,  or  of  quassia  and 
water,  will  sometimes  prove  sufficient.  Or  an  enema  com- 
posed of  one  to  four  drachms  of  spirit  of  turpentine  mixed 
with  the  yolk  of  an  egg,  and  added  to  four  to  eight  ounces  of 
water,  may  be  given  repeatedly  until  the  w  orms  are  destroyed. 
Two  drachms  of  asafoetida  or  aloes  in  water  also  answer 
equally  well. 

Astringent  enemata. — Solutions  of  many  of  the  well-known 
astringents,  both  vegetable  and  mineral,  may  be  used  for 
rectal  injection.  Among  the  former  is  gallic  acid,  two  grains 
of  which  should  be  mixed  with  each  ounce  of  w^ater.  The 
mineral  astringents  comprise  alum,  sulphates  of  copper  and 


698  THE    RECTUM 

zinc,  salts  of  iron,  acetate  of  lead,  and  nitrate  of  silver.  Most 
of  these  may  be  used  in  strengths  varying  from  one  to  three 
grains  of  the  salt  to  the  ounce  of  water.  Suppositories  of 
hamamelin  or  injections  of  hazeline  are  also  much  in  use. 

Sedative  enemata. — Enemata  of  this  description  are  more 
frequently  given  for  the  production  of  a  general  than  a  local 
effect.  And  inasrriuch  as  the  result  is  practically  the  same 
whether  the  drug  be  given  by  the  mouth  or  the  rectum,  all 
substances  in  the  pharmacopoeia  which  are  described  as  sedative 
in  their  effect  upon  the  nervous  system  can  be  introduced  — 
provided  the  form  is  suitable — as  well  by  the  rectum  as  by 
the  mouth.  Much  discussion  has  arisen  regarding  the  relative 
quantities  which  should  be  given  per  rectum,  as  compared  with 
what  is  usually  administered  by  the  mouth.  Eugene  Forster 
holds  that  from  his  experience  the  effect  produced  by  a 
certain  quantity  given  by  the  mouth  is  the  same  as  that  which 
results  from  the  same  quantity  given  j:)(?7'  rectum.  Others  main- 
tain that  ^proportionately  more  should  be  given  by  the  bowel ; 
while  there  are  those  who  contend  that  the  quantity  should 
be  proportionately  less.  The  simplest  plan  would  therefore 
seem  to  be,  and  certainly  the  safest,  to  prescribe  for  an  enema 
the  same  dose  as  that  given  for  administration  by  the  mouth. 
Among  narcotics  and  sedatives  which  may  be  used  as  enemata 
are  opium,  morphia,  belladonna,  stramonium,  cannabis  indica, 
asafoetida,  conium,  lobelia,  gelseminum,  musk,  chloral,  bro- 
mides of  potassium  and  sodium. 


INDEX   OF   NAMES 


Abbe,  101,  253,  257,  345,  347,  348,  380, 
477,  531,  535,  537,  542,  543 

Abel,  661 

Acker,  583 

Adams,  Jas.  A.,  220 

Adams,  T.  Eutherford,  607 

Adams,  Wm.,  12 

Adenot,  486 

Albert,  244,  524 

Allchin,  279,  280,  436 

Allen,  356 

Allingham,  H.  W.,  553 

Allingham,  Wm.,  222,  397,  401,  476, 
544, 552,  586, 590, 591,  601, 604, 611- 
3,  615,  631,  632,  641,  643,  673, 
679 

Allis,  513 

Almqvist,  229 

Aly,  418 

Amussat,  544 

Anders,  Ernst,  655,  662,  663,  668 

Anderson,  H.  A.  C,  293 

Anderson,  Wm.,  484 

Andrew,  Grant,  158,  337,  634 

Angerer,  221 

Annandale,  33,  55,  57,  58 

Arnot,  615 

Ashby,  390 

Atlee,  304 

Audry,  89 


Bacon,  692 

Ball,  Chas.  B.,  597,  603,  606,  612,615, 

637,  641,  661,  663,  670,  671 
Ball,  Wm.  T.,  36 
Ballance,  543 
Ballinger.  172,  173 
Ballot,  132 
Baltzer,  416 
Banks,  386 
Baracz,  255,  549 
Bardamant,  172 
Bardeleben,  222 
Barker,  A.  E.,  250,  252,  258,  386,  387, 

615,  535,  559 


Barker,  E.  J.,  608 

Barling,  501 

Barr,  342 

Barrs,  A.  G.,  351 

Bartolom^,  441 

Barton,  222 

Battle,  306,  310,  558 

Baur,  377 

Beamue!z,  631 

Beaumont,  148 

Beck,  162,  167,  170 

Bell,  646 

Benliam,  452 

Bennet,  Eisdon,  444 

Bennet,  W.  H.,  186,  188 

Berg,  172,  643,  652 

Bergmann,  von,  123,  124,  141,  142 

Berkham,  123 

Bernays,  171,  215,  268 

Bernheim,  294 

Berry,  Jas.,  75,  96,  456,  457 

Best,  172 

Bickersteth,  606 

Bier,  535 

Biggs,  280 

Billard,  40,  41,  42 

Bilroth,  80,  93, 180,  206,  207, 221,  251, 

252,  255,  263,  264,  434 
Bircher,  224,  225,  247 
Bird,  Golding,  239,  436 
Birmingham,  485 
Bishop,  526,  529,  530 
Blume,  C.  A.,  3,  49,  50 
Boas,  292 

Bodenhamer,  655,  661 
Bogdanik,  646 
Boiffin,  362 
Boisvert,  126 
Bond,  210 
Bonuzzi,  450 
Borelius,  685,  687 
Borri,  560 

Bowlby,  603,  604,  609,  636 
Boyd,  Francis  D.,  485 
Boyd,  Stanley,  13,  65 
Bradford,  174,  175,  18 


roo 


SURGEEY  OF  THE  ALIMENTARY  CANAL 


Braham,  J.  H.,  364 

Braillet,  301,  302 

Brandt,  248 

Branson,  342 

Briddon,  390,  392,  476 

Bridgeman,  26 

Brinton,  107,  108,  148 

Bristowe,  62,  113,  131,  344 

Broca,  363 

Brokaw,  256,  542 

Brown,  Lennox,  25 

Browne,  H.  L.,  92 

Bruce,  41 

Brush,  40 

Bryant  J.  D.,  490,  491 

Bryant,  Thomas,  236,  447,  449,  452, 

525,  544,  566,  596,  601,  604,  612, 

624,  641 
Buchwald,  411 
Bucquay,  278,  280,  281 
Buist,  158 

Bull,  222,  321,  323,  327,  447 
Buren,  van,  604,  643,  672,  674,  693 
Burghard,  596 
Burnet,  61,  66 
Butcher,  H.,  363 

Butlin,  16,  59,  62,  65,  117,  124,  141 
Buzzi,  422 
Byron,  661 


Cabot,  18 

Cadge,  568 

Cahill,  132 

Cahn,  290 

Callender,  390 

Callisen,  544 

Cameron,  Hector,  351,  494,  514 

Campbell,  137 

Campenon,  692 

Cant,  W.  T.,  168,  171 

Carmalt,  323,  327,  328 

Carpenter,  148 

Carver,  378,  389 

Cave,  E.  J.,  362,  363,  369,  370 

Chaff  ey,  19 

Championni^re,     Lucas,     368,     370, 

418 
Chapman,  82 
Chaput,  555 
Chavasse,  122,  123,  125 
Cheadle,  883,  384,  481 
Cheatham,  56 
Cheyne,  Watson,  371 
Chiari,  413 
Christie,  321 
Church,  21 
Churton,  132,  498 
Clark,  Sir  Andrew,  32 
Clark,  Henry  E.,  402 


Clarke,  Bruce,  384,  386,  403 

Clarke,  J.  J.,  668 

Clarke,  Jackson,  350,  351 

Clarke,  T.  Kilner,  253 

Clayton,  157,  158 

Cleghorn,  222 

Clutton,  103,  407,  468 

Coates,  362 

Coats,  Joseph,  47,  48,  56,  57,  201, 280, 

352,  354,  517 
Cohen,  Solis,  8,  18,  29,  31,  34,  36, 113, 

116,   126,  135,  141,  148,  155,  170, 

295,  447 
Collier,  J.,  274 
Collier,  Mayo,  107 
Collier,  William,  228 
Conant,  664,  668 
Condie,  41 
Conley,  306,  307 
Cook,  604 

Cooper,  589,  591,  604,  637,  6G1 
Cooper,  Astley,  351 
Cordier,  A.  H.,  364 
Cotterell,  Edward,  240,  385 
Coupland,  484,  607 
Courteen,  470 
Courtenay,  28 
Courvoisier,  255 
Cousins,  T.  Ward,  461 
Coutaret,  159 
Crary,  126,  128 
Crede,  598 
Cr6quy,  34 
Cripps,  Harrison,  240,  369,  370,  391, 

460,  549,  551-3,  562,  664,  565,  589, 

604,  606,  613,  622,  625,  653-5,  660- 

668,  674,  682 
Croft,  75,  306,  310,  311,  653 
Cropf,  417 
Cruveilhier,  658 
Cunningham,  119 

Curling,  277,  284,  286,  287,  655,  663 
Curnow,  434 
Curtis,  430 
Czerny,   80,   221,  260,  434,  528,  529, 

625,  626,  628,  629, 689 


Dalton,  462,  467 

Dalziel,  T.  K.,  185,  188 

Daniel,  503 

Danzel,  608 

Davy,  113,  114,  116,  130,  568 

Dawbarn,  255,  538 

Dean,  282,  283,  296,  363 

Debove,  48,  87,  91 

Dechambre,  100 

Dehio,  155 

Demoulin,  515 

Dent,  363 


INDEX    OF   NAMES 


701 


Desmos,  G3 

Dewhurst,  181 

Dexter,  422,  4S3 

Dickinson,  Lee,  193,  194,  19G 

Dickson,  170 

Dieulafoy,  22  J 

Dionisi,  4(5 

Dixon,  9(5 

Dodd,  30,  485 

DorHer,  303,  3G5,  390,  392 

Doyle,  H.  Martin,  20 

Doyle,  J.  P.,  442 

Draper,  517 

Duchcneau,  205 

Duffin,  34 

Dunlap,  338 

Dunn,  L.  A.,  180,  189,  OOG 

Dupuytren,  555 

Duret,  225,  248 

Durham,  A.,  75 

Dyson,  408 


Earle,  5G7,  599 

E berth,  51 

Ebstein,  200 

Eccles,  379,  384 

Eddison,  51 

Edmunds,  543 

Edwards,  589,  591,  004,  037 

Egebert,  232,  242,  244 

Einhorn,  112-114,  117,  150,  150 

Eiselsberg,  204 

Eisendrath,  505 

Eklund,  101 

Eloy,  107,  111 

Emerson,  293,  294 

Emmet,  054 

Erichsen,  157,  273 

Esson,  300 

Eve,  22,  95,  100,  281,  283,  337,   380, 

404,  406,  408 
Ewald,  149,  150,  153,   155,   180,   208, 

209,  696 


Fagge,  Hilton,  55-7,  128,   129,    1S2, 

207,  397,  636 
Fairweather,  497 
Fehleisen,  208 
Fenger,  232,  233 
Fen  wick.  Hurry,  573,  070 
Fenwick,  W.  Soltau,  228,  229 
Fere,  118 
Ferguson,  222 
Ferrier,  601 

Finlayson,  Jas.,  47,  06,  07,  71,  4G8 
Finney,  30,  452 
Finny,  61 
Fitz,  10,  11,  492,  507 


Fleming,  R.  A.,  154 

Fleming,  W.  J.,  415,  41G 

Flexner,  53 

Floyer,  404 

Formad,  478 

Forster,  Eugene,  694,  69G,  698 

Fort,  72,  98 

Foulerton,  463 

Fowler,  G.  Ryerson,  351,  369,  482, 492 

490-8,  500,  504,  507,  508,  512,  568, 

649 
Fox,  Wilson,  281 
Foxwell,  288 
Foy,  230 
Francis,  117,  119 
Frank,  R.,  232,  244 
Franklin,  361,  303 
Franks,  Kendal,  89,  94,  97,  98,  101, 

464,  465,  474,  525 
Frantzel,  205 
Freeman,  274,  27G 
Friedrich,  50 
Fry,  H.  A.,  42 
Fuller,  061 
Fiitterer,  484 


Gairdner,  John,  303 

Gairdner,  W.  T.,  21,  283 

Gant,  70 

Garr6,  395,  400 

Gaucher,  71 

Gautier,  33 

Gerard,  241 

Gerster,  320,  321,  686,  688,  60O 

Gersuny,  75,  77,  78,  691 

Gibbs,  John  Blair,  577,  585,  58G 

Gilford,  H.,  185,  188 

GMnard,  227,  248 

Glover,  29 

Godlee,  R.,  12,  386,  579 

Godwin,  613 

Goerne,  577 

Goodhart,  16,  436 

Goodsall,  571,  604 

Gordon,  198 

Goselin,  604 

Goubaux,  108 

Gould,  452 

Gowlland,  004,  612 

Gradenwitz,  114,  110 

Grandon,  126 

Grant,  542 

Griffith,  30G 

Gross,  Chas.,  G 

Gross,  Sam.  D.,  001 

Guinard,  220,  221 

Gull,  172 

Giinzburg,  151 

Gussenbauer,  434 


(03 


SURGERY   OF   THE   ALIMENTARY    CANAL 


Habeeshon,  106 

Hacker,  von,  23,  134,  142,  232,  240-2, 

255 
Hadden,  61,  206,  433,  454 
Hadra,  242 

Hahn,  220,  223,  227,  232,  211,  244 
Hall,  183 
Halsted,  535,  543 
Hamilton,  483 
Handford,  112,  206,  462,  603 
Hannay,  113,  116 
Hardie,  Jas.,  27 
Harrison,  C.  E.,  11 
Harrison,  E.,  335 
Harte,  501 

Hartley,  206,  207,  692 
Harvey,  92 
Hashimoto,  167 

Haward,  W.,  187,  189,  364,  480 
Hawkins,  342,  343,  390 
Hayden,  133 
Heath,  13 
Heaton,  636 
Hebb,  277,  280 
Heelis,  274 
Hegar,  685,  686 
Heigl,  256 
Heineke,  100,  215,  222,  205,  266,  292, 

401,  443,  543,  685 
Henschell,  72 
Herczel,  600 
Hering,  156 
Herringham,  479 
Heuck,  612,  614,  629 
Heuston,  467 
Hildebrand,  612,  630 
Hilton,  182 
Hirschsprung,  478 
Hobson,  293 

Hochenegg,  684,  6C0,  091 
Hochhaus,  292 
Hoden,  60 
Hoffman,  120 
Hofmokl,  434,  463,  477 
Hogner,  229 

Holmes,  T.,  127,  186,  267,  286,  676 
Hoist,  607 
Holt,  483 
Hood,  306 
Hook,  van,  345,  347 
Howse,  232,  234,  235,  238,  241 
Huber,  125 
Hudson,  420,  422,  423 
Hughes,  182 
Huike,  670 
Hunter,  285 
Hurd,  484 
Hutchinson,  Jonathan,  37,  274,  275, 

363,  383,  390,  404,  451 
Hvrtl,  119 


Ingals,  89 
Inman,  172 
Irving,  362 

Jacob^us,  Mathias,  43 

Jacobson,  241,  263 

Jacques,  240 

James,  David,  56,  57 

Jeannel,  655 

Jenkins,  572 

Jessett,  208,  217,  221-3,  236,249,  256, 

523,  535,  540 
Jessop,  498 
Joal,  46,  51,  107 
Jobert,  528 
Johnson,  467,  471 
Jonch^res,  467 
Jones,  J.  Harris,  607 
Jones,  Eobert,  363,  366 
Jones,  Sydney,  232,  674 
Jones,  Thomas,  369,  370 
Jonnesco,  351 
Jowers,  E.  F.,  185,  188 

Kammeree,  646,  689 

Kappeler,  80 

East,  289 

Kauffmann,  418 

Keen,  260 

Kelsey,  Chas.  B.,  551,  555,  580,  592, 

601,  612,  648,  658,  661,   670,   071, 

675,  680,  686 
Kelynack,  277,  517 
Kempe,  87 
Kennicutt,  222 
Khalofoff,  454 
Kleberg,  642,  648 
Klebs,  113 
Kleef,  180 
Klein,  Gustav,  63 
Kidd,  459,  463 
Knaggs,  384 
Knott,  114,  131 
Knox,  D.  N.,  439 
Koch,  363 
Kocher,  124,   141,  142,  220,  252,  255, 

685 
Koehler,  104 
Konig,  124,  394 
Kooyker,  172 
K5rte,  386,  408,  434,  453 
Kraske,  634,  683,  686,  689,  692 
Krauss,  277 
Kriege,  185,  188 
Krishaber,  75,  79 
Krogius,  199 
Kronlein,  35 
Kunze,  201 
Kussmaul,  228,  486 
Kiister,  181,  689 


INDEX    OF   NAMES 


rO:3 


Lacombe,  67,  100 

Lane,  W.  A.,  408,  409,  503,  515,  520 

Lange,  99,   ISO,  2.)2,    293,  296,  385, 

589,  636,  ()43,  652,  690,  692 
Langenbuch,172, 205, 223, 246, 295, 296 
Ijangenhaus,  44 
Langhaus,  413 
Larkin,  260 
Latham,  119 

Lauenstein,  221,  227,  260,  389,  552 
Leichtenstern,  113,  119,  355,  361,410, 

517 
Leiter,  24,  155,  567 
Lembert,  529 
Letuille,  51 
Leube,  GJ4 
Leven,  126,  127 
Levy,  20^,  685,686 
Lewis,  637 
Leyden,  193,  344 
Lilienthal,  475 
Limont,  159,  160,  222 
Lindermann,  386 
Link,  463 
Lisfranc,  681 
Littlewood,  256,  369,  537 
Lockwood,  283,  375,  386,  481,  482,484, 

509 
Logan,  638,  641 
Loreta,  97,  215,  222,  267 
Louis,  344,  345 
Lovinsohn,  614,  626,  629 
Lowe,  572,  574,  654 
Lowson,  167,  222 
Lubarsch,  413 
Lubinski,  87,  88 
Liicke,  221,  344,  347 
Lundie,  E.  A.,  186,  183 
Luschka,  113 

Maas,  671 

McAUster,  391,  392 

McArdle,  452 

McBumey,385,  492,500,503,  515,  557, 

558 
McCall,  342 
McCarthy,  487 
MacCormac,  96 
McCosh,  606,  610,  685,  637 
MacEwen,  Wm.,  385 
McGill,  556 
McGraw,  257,  260,  322 
McIh-aHh,  17 
Maclntyre,  John,  18,  24 
Mackenzie,  Hunter,  68 
Mackenzie,  H.  W.  G.,  278 
Mackenzie,  Morrell,  Sir,  2,   8,  17,  23, 

24,  34,  38-41,  45,  46,  49-51,  51,  53, 

57,  59,  68,  75,  80,  86,  99,  111,  115, 

125,  132 


Maclaren,  R.,  186 

MacLennan,  Alex.,  445,  635 

McLeod,  K.,  642,  651 

McNutt,  447 

McWeeny,  438 

McWhinnie,  228 

Macan,  607 

Machel,  126 

Madelung,  415,  416 

Magill,  221,  258 

Makins,  377,  379,  526 

Mandach,  124 

Marcus,  619 

Marcy,  639 

Mar3h,F.,  619 

Marsh,  Howard,  128,  SCO,  333,   377, 

385,  609 
Marshall,  George,  402 
Marshall,  John,  276 
Marten,  228 
Martius,  De  Souza,  342 
Masimoff,  640 
Mathieu,  203 

Matthews,  561,   566,   584,   539,    604, 

631,  673 
Maunsell,  532,  543,  692 
Maurer,  180 

Maurice,  W.  J.,  183,  189 
May,  172,  205 
Maydl,  524,  551,  553 
Mayet,  694 

Mayo,  W.  J.,  101,  256,  451,  452,  612 
Mazotti,  53 

Mears,  J.  Ewing,  345,  347,  454 
Mekins,  126 
Melsome,  483 
Mentin,  453 
Mercer,  410 
Mercier,  660 
Mermod,  116 
Meyer,  W.,   99,   101,   242,  243,    244, 

386,  418 
Middledorpf,  160 
Middleton,  George,  456,  458 
MikuUcz,  24,  155,  180,  184,  215,  244, 

265,  266,  292,  401,  443,  543,  012 
Miles,  323 
Minor,  158 
Minowski,  209 
Mintz,  121,  123 
Mixter,  124 
Monakow,  126,  130 
Mondiere,  104 
Money,  468,  479 
Monprofit,  362 
Monro,  T.  K.,  404,  446 
Montaut,  104 
Moore,  N.,  62,  121,  278,  279,  230,  289, 

434,  469 
Moorhead,  J..  112 


iOi 


SURGERY  OF  THE  ALIMENTARY  CANAL 


Morejon,  85 

Morgan,  658 

Blorison,  542 

Morley,  14 

Morris,  H.,  158,  187,  189,  508 

Morrison,  Eutherford,  82 

Morse,  J.  H.,  185 

Morton,  Charles  A.,  413,  414,  473 

Morton,  Thomas  G.,  287 

MouUin,  Mansell,  553,  663 

Mouton,  3 

Moxon,  43,  47,  61,  87,  432,  450 

Moyes,  John,  486 

Moynihan,  508 

Munro,  483 

Murchison,  403,  404 

Murphy,  221,  256,  260,  263,  264,  364, 

365,  370, 541,  547,  689,  691 
Murray,  F.  W.,  101 
Murray,  H.  M.,  201,  281 
Myers,  281 
Mygind,  396,  401 
Myles,  409 

Napieb,  Alexander,  506 
Nassiloff,  80,  143 
N61aton,  522 
Nepveu,  637 
Newman,  David,  62,  81 
Newman,  E,  60,  65,  599 
Nicaise,  568 
Nichols,  331,  332 
Nicholson,  E.  H.  B.,  186 
Nicolaysen,  363   . 
Nordman,  568 
Norman,  201 
Nothnagel,  375 

Obalinski,  550 
Obre,  676 
Ochener,  386 
Ochsner,  452 
O'Connor,  378,  379 
Oderfeld,  356,  361,  363 
Oestreich,  478 
Ogston,  4 
Oliver,  432 
Ord,  178 
Ormerod,  436 
Osgood,  109 
Osier,  478 
Owles,  72 

Page,  F.,  60,  71,  159,  160,  222,  303, 

304,  660 
Paget,  G.  E.,  65 
Paget,  Sir  James,  107 
Paget,  Stephen,  663,  664,  667,  670 
Painter,  98,  137 


Pariser,  156 

Parker,  Chas.  A.,  432 

Parker,  C.  T.,  189,  227,  312 

Parker,  Eushton,  352,  363 

Parker,  E.  W.,  384 

Parmentier,  62 

Parsons,  A.  E.,  181,  187, 189, 192,  209, 

282 
Pasteur,  W.,  191 
Paterson,  John,  634 
Paul,  F.,  187,  189,  257,  369,  370,  473, 

475,  538,  539,  547 
Pean,  401,  443,  543 
Pennington,  390 
Penzold,  151 
Perlick,  210 
Pernice,  210 

Perry,  206,  207,  209,  357,  416 
Pick,  Pickering,  195,  364,  386 
Pietkiewicz,  43 
Pisko,  170 
Pitt,  N.,  47,  210,  390,  395-7,  436,  477, 

636 
Pitts,  619 
Planchard,  280 
Poel,  338 

Poelchen,  581,  586,  590,  591 
Poland,  157,  273,  302-4,  306,  310,  430 
PoUailon,  168 

Pollard,  Bilton,  186,  188,  384 
Pollock,  157,  160,  172 
Porak,  294 
Porges,  246 
Port,  608,  610 
Portarca,  139 
Postempski,  180 
Postnikow,  257 
Potain,  87 

Poulet,  17,  30,  33,  167,  171,  572 
Poulsen,  142 
Poulton,  617 
Powell,  464 
Power,  448 
Preble,  30 
Price,  Parry,  62 
Prideaux,  607,  610 
Puech,  46 
PuUin,  379 
Purton,  113,  115,  116 
Puzey,  317 

QuAiN,  613 
Quenu,  140,  640 

Eabagliati,  362 
Eansom,  413 
Eatcliife,  J.  E.,  49 
Eawdon,  253 
Eay,  182 


INDEX    OF    NAMKS 


roo 


Becliis,  554 

Reher,  48,  70 

Rehn,  (;85,  680,  092 

Reichmann,  von,  43,  121,  156 

llennie,  695 

Rente  n,  T.  Crawford,  202,  380 

Renvers,  75,  94,  150 

Repetto,  162 

Reverclin,  476 

Ribbert,  489 

Ricard,  418 

Richardson,  B.  W.,  74 

Richardson,  Maurice,  31,  35,  30,  507, 

508 
Richelot,  001 
Richter,  100,  092 
Ricord,  001 
Ridley,  G.  W.,  386 
Rieder,  394 
Riegel,  413,  414 
Ritchie,  172 
Rizzoli,  005 
Roberts,  323 

Roberts,  John  B.,  042,  644,  045 
Robertson,  295,  296 
Robinson,  F.  B.,  257,  538,  540 
Robinson,  H.  Betham,  433 
Robson,  Mayo,  175,  198,  220,  307,  390, 

392,  402,  403,  408,   430,  447,  449, 

474,  540,  547 
Eochard,  444 
Rockwell,  306 
Rockwitz,  251 
Rodman,  C.  H.,  77 
Roe,  99 
Rohe,  368 
Rokitansky,  50,  57 
Rolleston,  W.  D.,  84, 114,  289,  294,  397, 

422,  439,  480 
Roosevelt,  61,  65,  66,  71 
Roper,  278 
Eosenbach,  82 
Rosenheim,  227 
Rosenthal,  389 
Roughton,  E.  W.,  386 
Roupell,  228 
Routier,  680 
Roux,  452 
Rowan,  661 
Rowland,  Sidney,  330 
Rumpel,  289 
Rushmore,  498 
Russell,  172 

Rutherfurd,  H  ,  24,  415,  416 
Eydygier,  220,  221,  685,  686,  690 

Sabrazes,  199 
Sachs,  434 
Sainsbury,  404 
Salter,  194 


Sands,  93 

Sansom,  095 

Saundby,  149 

Schech,  39 

Schede,  089 

Scheimpflug,  239 

Scherming,  497 

Schiach,  339 

Schiltz,  80 

Schmidt,  620,  629 

Schoening,  613 

Schonborn,  172 

Schroeder,  409,  410 

Schwartz,  444 

Scott,  323 

Sedillot,  232 

Sellew,  438 

Senator,  78,  97 

Sendler,  465 

Senn,   252,   253,  255,  256,  260,  263, 

322,  344,  345,  452,  535,  537,  556 
Sharkey,  27,  55,  436 
Shattock,  126,  127,  605,  606 
Shaw,  Lauriston,  83,  206,   207,   209, 

447 
Sheild,  Marmaduke,  604,  605 
Shepherd,  386 
Silcock,  A.  Q.,  188,  189 
Silver,  20 

Simmons,  572,  574 
Simon,  342,  566 
Sinclair,  66 

Smith,  Eustace,  444,  481 
Smith,  Greig,  222,  232,  235,  411,  412, 

418,  549 
Smith,  Henry,  041,  643,  676 
Smith,  L.,  364 
Smith,  Parsons,  607 
Smith,  Pye,  351,  384,  460 
Smith,  T.,  603,  605 
Smith,  Walter,  65,  71 
Southam,  286,  288,  295,  290,  303,  456 
Spanton,  572,  576 
Squires,  457 
Ssabanejew,  244 
Stalkert,  571 
Stanley,  390 
Stansfield,  260 
Steavenson,  136 
Steele,  126,  127 
Stephan,  58,  84 
Steven,  Lindsay,  207,  219,  415 
Stierlin,  612,  614 
Stimson,  307,  317,  319,  323,  516 
Stockwell,  65 
Stoker,  Thornley,  512 
Stretton,  J.  L.,  386 
Struthers,  119,  489 
Surmay,  295 
Sutclift'e,  449 


Z  Z 


ro6 


SURGERY  OF  THE  ALIMENTARY  CANAL 


Sutlierland,  Lewis,  517 

Sutton,  166,  422 

Svenson,  281 

Swain,  Paul,  222,  268,  665 

Syme,  32,  34 

Symington,  684 

Symonds,   75,   77,   79,   94,  447,  449, 

468 
Sympson,  571 

Talamon,  516 

Targett,  83,  304,  437 

Taylor,  F.  W.,  126 

Taylor,  Joseph,  29 

Taylor,  J.  W.,  187,  189,  209 

Taylor,  W.  C.  E.,  403,  404,  408, 
417 

Templeton,  306,  309 

Terrier,  671 

Terrillon,  96,  406,  408 

Thiersch,  101 

Thiery,  363 

Thiriar,  408 

Thomas,  Hugh,  19 

Thomas,  Wm.,  423 

Thomson,  H.,  364 

Thomson,  John,  422,  423 

Thomson,  J.  H.,  570 

Thomson,  E.  E.,  382,  385 

Thomson,  Wm.,  22 

Thorndike,  691 

Thornton,  Knowsley,  172 

Thornton,  W,  P.,  65 

Tietze,  96,  96 

Tiffany,  164,  324 

Tirard,  482 

Tito-Carbone,  411 

Tooth,  435 

Townley,  P.  L.,  571 

Traube,  154 

Tr61at,  444,  670 

Tremaine,  319 

Trendelenburg,  102,  557 

Treves,  Frederick,  107,  174,  175,  182, 
222,  226,  268,  272,  355,  361,  375, 
393,  396,  401,  404,  405,  409,  425-7, 
438,  439,  444,  455,  458,  507,  508, 
510,  514,  523,  526,  557,  559,  632, 
642,  647 

Troisier,  204 

Tuholske,  265 

Turner,  F.  Charlewood,  126,  128,  129, 
421 

Turner,  G.  E.,  392 

Uhlmann,  692 

Veeneuil,  642,  679,  693 
Vernon,  H.,  408 
Verral,  386 


Vince,  J.  Foster,  126,  128 

Viti,  50,  115 

Voehts,  339,  340,  341,  394 

Voelcker,  133 

Voigt,  89 

Volkmann,  629,  646 

Voss,  607 

Wagstafee,  616 

Walker,  477 

WaUis,  281 

Walsham,  450,  566 

Walters,  J.  H.,  186,  189 

Warren,  572 

Wasker,  van  de,  21 

Way,  617 

Weichselbaum,  53,  54,  468 

Weinlechner,  86,  92,  121,  123 

Weir,  Eobert  F.,  140,  224,  225,  247 

Wepier,  104 

West,  193,  205,  281,  369 

Whipham,  195 

White,  Hale,  210,  410,  434,  436,  484 

White,  J.  A.  H.,  306,  310 

White,  J.  William,  24,  344 

Whitehead,  123 

Whitla,  97 

Whitmore,  599 

Whittier,  289 

Wiggin,  306,  311 

Wilks,  43,  47,  61,  87,   113,  116,   128, 

129,  419,  432,  450 
Willems,  690 
Willet,  422 
Williams,  Alfred,  22 
WilUams,  John  T.  C,  383,  463,  612 
Williamson,  311 
Wilms,  80 

Wilson,  Andrew,  158 
Wilson,  Arthur  H.,  164 
Wilson,  J.  Stacy,  49 
Wilson,  Prof.,  104 
Witzel,  232,  242-4,  690 
Wolfler,   199,  200,  220,  221,  223,  249, 

254,  255,  529,  687,  688 
Woods,  277 
Wooldridge,  180 
Woolsey,  101,  323 
Worrall,  455 
Wright,  G.  A.,  363 
Wyatt,  61  .        . 

Wyss,  55 

Yaek,  274 

Zemann,  53 

Zenker,  Konrad,  51,  53,  88,  113,  120, 

125,  131 
Ziemssen,  von,  53,  56,  125,  129,  355 

Zuckerkandl,  687,  688 


INDEX  OF  SUBJECTS 


Abbe's  catgut  rings  in    intestinal  co- 
aptation, 256 

—  string  method  in  cicatricial  stenosis 
of  oesophagus,  100 

—  suture  in  bowel  union,  531 
Abnormalities  of  intestine,  great,  480 

—  of  intestine,  small,  420 

—  of  oesophagus,  112 

—  of  rectum,  654 

Abscess  due  to  appendicitis,  501,  502, 

493 
treatment  of,  510,  513 

—  due  to  carcinoma,  great  intestine, 
467,472 

rectum,  617 

—  due  to  contusion,   small  intestine, 
303 

—  —  diveiiiculum  of  rectum,  671 
duodenal  ulcer,  281 

foreign  body  in  intestine,  330 

gunshot  wound  of  intestine,  322 

—  in  liver  due  to  carcinoma  of  great 
intestine,  468,  470 

—  localised,  result  of  tubercular  ulce- 
ration, small  intestine,  341 

—  localised,  result  of  typhoid  ulcera- 
tion, small  intestine,  341 

—  perinephric,    ulcerating   into    duo- 
denum, 295 

—  perirectal,  569,  575,  592 

—  post-oesophageal,  20,  21 

—  post-Cfecal,  468 

—  pressure   of,  affecting   oesophagus, 
131,  132 

giving  rise  to  intestinal  obstruc- 
tion, 418 

—  result  of  perforation,  small  intes- 
tine, 398 

—  rupturing  into  rectum,  673 

—  secondary  to  gastric  ulcer,  192 

—  —  to  carcinoma  of  stomach,  205 

to  stricture  of  great  intestine,  439 

to  stricture  of  rectum,  670 

—  subdiaphragmatic,  193 

—  submucous,  of  cesophagus,  46 


Abscess  in  ulcer,  perforated,  great  in- 
testine, 432,  437 
stercoral,  great  intestine,  457 

—  in  ulceration,  tubercular,  of  rectum, 
583 

Absorption,  fascal,  in  fsecal  accumula- 
tion, 458 
Accumulation,  facal,  great  intestine, 
455 

as  a  cause  of  proctitis,  577 

stricture  of  rectum,  591 

■ ulceration  of  rectum,  581 

Acid,  carbolic,  injection  of,  as  a  cause 
of  proctitis,  577 

—  nitric,  in  rectal  prolapse,  641 

—  tannic,  in  rectal  prolapse,  641 
Acids  as  a  cause  of  stenosis  of   oeso- 
phagus, 85 

Actinomycosis  as  a  cause  of  appendi- 
citis, 496 
Adenomata  of  great  intestine,  462 

—  of  small  intestine,  411 

—  of  oesophagus,  55 

—  of  rectum,  602 

—  of  stomach,  202 

Adeno-sarcoma  of  great  intestine,  477 
Adenoid  carcinoma  of  great  intestine, 

466 

of  rectum,  614 

Adhesion  between  layers  in  intussus- 
ception, 377 

Adhesions  in  appendicitis,  514 

—  in  gastric  ulcer,  198 

—  of  stomach,  giving  rise  to  dilatation, 
226 

—  in  acute  strangulation,  368,  446 

—  in  stricture,  small  intestine,  398 

—  in  volvulus,  390,  450 

Albert's  modification  of  jejunostomy, 

523 
Alimentation,  rectal,  693 
Alkalies,  caustic,  as  a  cause  of  stenosis 

of  resophagus,  85 
Amputation  of  rectal  prolapse,  646 
Amussat's  operation  of  colostomy,  54i 


708 


SURGEEV    OF   THE    A.LIMENTARY   CANAL 


Anaesthetic  in  impacted  foreign  body 
of  (jbsophagus,  28 

Anatomy,  surgical,  of  appendix  vermi- 
formis,  489 

intestine,  great,  425 

small,  271,  297 

oesophagus,  1 

rectum,  561 

■ stomach,  145 

Aneurysm,  aortic,  causing  pyloric  ob- 
struction, 209,  226 

■ differential  diagnosis,  from  car- 
cinoma of  (Esophagus,  69 

—  aorta,  pressure  of,  on  oesophagus, 
131 

Angeioma,  lipomatous,  of  great  intes- 
tine, 463 
Angeiomata  of  rectum,  608 
Anus,  artificial,  closure  of,  555 

formation  of  (method),  550 

in  atresia  recti,  666 

in  carcinoma  of  great  intes- 
tine, 476 

•  —  in  carcinoma  of  rectum,  624, 

630,  633,  634 

in  dilatation,  great  intestine, 

479, 480 

in  dysentery,  579 

in  intussusception,  387 

— occlusion  of  bowel,  422 

in  rupture  of  bowel,  312 

•  —  in  strangulation,  internal,  365 

in  stricture,  intestinal,  400 

—  of  rectum,  593,  601 

in  ulcer,  typhoid  (perforated) , 

347 

— —  in  ulceration  of  rectum,  583 

— —  in  volvulus,  392 

—  in  wounds,    small  intestine, 

317 

previous  to  proctectomy,  680 

— result  of    injury  to    bowel  and 

abdominal  wall,  303 

—  condition  of,  in  carcinoma  of 
rectum,  618 

—  lumbar,  formation  of,  554 

—  sacral,  in  carcinoma  of  rectum, 
634 

—  sigmoid,  formation  of,  550 
in  atresia  recti,  663 

■ in   carcinoma  of   rectum,   635, 

669 
Aorta,   dilated,   causing  dilatation  of 

oesophagus,  112 

—  perforated  by  bonfe  impacted  in 
oesophagus,  22 

—  rupture  of,  by  oesophageal  probang, 
32 

—  ulceration  of  oesophageal  carcinoma 
extending  into,  65 


Apertures,  adventitious  or  congenital, 

strangulation  through,  351 
Aphonia  in  carcinoma  of  oesophagus, 

66,  71 
Aphthous  oesophagitis,  44 
Appendicectomy,  operation  of,  557 

—  reference  to,  505,  508,  510 
Appendices    epiploic^,    anatomy    of, 

427 

—  lipomata  in  connection  with,  463 

—  strangulation  caused  by,  356 
Appendicitis,  491 

—  diagnosis  of,  503 

—  etiology  of,  494 

—  pathology  of,  492 

—  prognosis  of,  506 

—  symptoms  of,  497 

—  treatment  of,  509 
Appendix,  vermiformis,  489 

—  anatomy  of,  489 

—  carcinoma  of,  516 

—  cystic  disease  of,  517 

—  foreign  bodies  of,  491,  496 

—  inflammation  of,  491 

—  removal  of,  557 

—  situation  of,  490 

—  strangulation  caused  by,  356,  361, 
364,  370 

—  structure  of,  490 

Ascaris  lumbricoides  in  stomach,  166 
Aspiration  of  stomach,  229 
Astringent    injections   in   rectal   pro- 
lapse, 641 
Atresia  ani,  657 

—  congenital,  of  oesophagus,  126 

—  recti,  657 

Atrophy,  muscular,  causing  dilatation 
of  oesophagus,  113 

Bacillus  coli  communis  in  appen- 
dicitis, 495 

Bags,  elastic,  for  dilating  oesophagus, 
33 

'  Ballooning  '  of  bowel  in  obstruction, 
443 

—  of  rectum  from  stricture,  593,  596, 
618 

Bands,  strangulation  by,  354 
Bartholin's    glands,  inflammation  of, 

giving  rise  to  ulceration  of  rectum, 

586 
Bernay's  curettage  of  pylorus,  268 
Bishop's  suture  in  bowel  union,  530 
Bladder  affected  in  appendicitis,  501 

—  fistulous,  communication  between 
appendix  and, 493,  514 

—  —  communication  between  colon 
and,  467,  472,  484 

communication  between  rectum 

and,  575,  592,  617,  634 


INDEX    OF   SUBJECTS 


709 


Bladder,  foreign  body,  intestinal,  rup- 
turing into,  334 

—  pressure  on,  in  fsecal  accumulation, 
456 

—  rectum  opening  into  (congenital), 
657,  660,  665 

—  stone  in,  as  a  cause  of  rectal  pro- 
lapse, 638 

^  tumours  of,  pressing  on  rectum, 
676 

Blood,  defibrinated,  as  a  nutrient 
enema,  695 

Blow  on  abdomen,  as  a  cause  of  vol- 
vulus, 3i)0 

—  —  resulting  in  stricture,  396 
Bobbins,  bone,  bowel  union  by,  540 
Bone    bobbins,    union  by  (Eobson's), 

540 

—  plates,  union  by  (Senn's),  535 

—  tubes,  union  by  (Littlewood's),  537 
Borelius'  method  of  proctectomy,  687 
Bougie,  hollow,  in  removing  fish  bone 

from  oesophagus,  34 

—  in  atresia  of  oesophagus,  127 

—  in  paralysis  of  oesophagus,  105 

—  in  treatment  of  diverticulum  of 
oesophagus,  124 

—  in  treatment  of  impacted  foreign 
body  of  oesophagus,  23,  31,  32 

—  in  treatment  of  cicatricial  stenosis 
of  cesophagus,  93 

—  in  treatment  of  congenital  stenosis 
of  oesophagus,  129 

—  in  treatment  of  spasm  of  oesophagus, 
110 

Bougies,  injury  to  rectum  by,  568 

—  introduction  of,  in  affections  of 
oesophagus,  134 

—  use  of,  in  rectal  affections,  667 
in  stricture  of  rectum,  594,  593, 

622 
Bowel  union,  528 
Brain,  secondary  involvement   of,   in 

carcinoma  of  rectum,  619 
Branchial  cleft,  non-closure  of,  as  a 

cause  of  diverticulum  of  oesophagus, 

117 
Brokaw's  rubber  rings  in  intestinal  co- 
aptation, 256 
Bronchocele,   substernal,  pressing  on 

oesophagus,  132 
Brunner's  glands,  272,  284,  298 
Bullet,  difference  in  wound  according 

to  nature  of,  320,  327 
Burns  as  a  cause  of  acute  duodenal 

ulceration,  284 

—  of  oesophagus,  4 

Buttock,  rectum  opening  into,  657 
Button,  Murphy's,  description  of,  256 

—  bowel  union  by,  541 


Cachexia  in  carcinoma  of  rectum,  619, 

634 
Cfficectomy,  operation  of,  546 
Ciecitis,  431 
Ciscum,  anatomy  of,  425 

—  fffical  accumulation  at,  455 

—  fibroma  of,  463 

—  misplacement  of,  482 

—  rupture  of,  617 

—  ulcer  of,  434,  437 

Callisen's  operation  of  colostomy,  544 
Carcinoma  of  appendix,  516 

—  of  duodenum,  289 

—  of  intestine,  great,  464 

—  of  intestine,  small,  412 

—  of  liver  simulating  obstruction  of 
oesophagus,  70 

— ■  of  liver  as  a  cause  of  spasm  of 
aisophagus,  107 

—  of  oesophagus,  58 

—  of  pylorus,  209 

—  of  rectum,  612 

—  of  stomach  wall,  202 
Catarrhal  appendicitis,  493 

—  oesophagitis,  46 

—  ulcer  of  great  intestine,  437 
Catheter,     railway,     in     oesophageal 

stenosis,  96 

Catheterisation  in  diverticula  of  oeso- 
phagus, 124 

Cauterisation  in  carcinoma  of  oesopha- 
gus, 80 

Cautery,  thermo-,  in  gastric  ulcer, 
181 

—  in  rectal  prolapse,  643,  693 
Cellulitis  of  perirectal  tissue,  580 

—  pelvic,  rupturing  into  rectum,  674 
Cervical  oesophagotomy,  137 
Chaput's  operation  for  closure  of  arti- 
ficial anus,  555 

Cholecyst-enterostomy,   operation   of, 

560 
Chorea  in  spasm  of  oesophagus,  107 
Cicatricial  stricture  of  duodenum,  291 

—  intestine,  great,  438 
small,  393 

—  oesophagus,  84 

—  rectum,  590 

Cicatrisation  of  gastric  ulcer,  effects, 

200 
Cirrhosis  of  liver  as  a  cause  of  varix 

of  oesophagus,  19 
Clamp  and  cautery  in  rectal  ijrolapse, 

643,  693 
Clavicle,  dislocacion   of,   pressing  on 

(esophagus,  131 
Coin  in  oesophagus,  19,  24,  26,  27 

cases  of,  35 

Coin  catcher,  description  of,  25,  31,  32 
Colectomy,  operation  of,  546 


^'10 


SURGERY   OF  THE  ALIMENTARY  CANAL 


Colectomy  in  carcinoma,  great  intes- 
tine, 474 
Colic,  appendicular,  498 

—  variety  of  intussusception,  447 
Colitis,  431 

—  membranous,  436,  438 

—  ulcerative,  435 

Collapse    after    gastro  -  enterostomy, 

258 
Colloid  carcinoma  of  intestine,  great, 

465 

—  of  oesophagus,  62 
- —  of  rectum,  615 

Colon  (see  Intestine,  great) 
Colopexy,  operation  of,  550 

—  in  rectal  prolapse,  652 
Colo-reetostomy,  of  Uhlmann,  692 
Colostomy,  operation  of,  544 

—  in  atresia  recti,  666 

■ —  in  carcinoma,  great  intestine,  473, 

476 
■ —  in  faecal  accumulation,  460 

—  in  ulcerative  colitis,  436 

— •  in  volvulus,  great  intestine,  452 
Colostomy,  gastro-,  operation  of,  248 
Colotomy,  operation  of,  544 
Concretions  of  rectum,  573 
Congenital  abnormalities  of  intestine, 
great,  480 

—  of  intestine,  small,  420 

—  of  oesophagus,  112 

—  of  rectum,  654 

Constipation  in  carcinoma  of  rectum, 
620 

—  as  a  cause  of  rectal  prolapse,  638 
Contusion  of  intestine,  small,  300 

—  of  stomach,  156 

Convulsions   in   faecal    accumulation, 

457 
Credo's  rectal  bougie,  598 
Cripps'  operationior  sigmoid  anus,  552 
Croupous  oesophagitis,  46 
Cryptoscope  in  impacted  foreign  bodies 

in  oesophagus,  24 
Curetting    in   carcinoma   of    rectum, 

632 

—  in  pyloric  obstruction,  215,  224,  268 
Curvature,  spinal,  affecting  oesophagus, 

134 

Cystenterostomy,  560 

Cystic  disease  of  appendix,  517 

Cystoma,  ovarian,  giving  rise  to   in- 
testinal obstruction,  418 

Cystomata  of  rectum,  607,  610 

Cysts  of  intestine,  great,  464 

small,  411 

—  of  oesophagus,  55 
—  of  stomach,  202 

Czerny,  Lembert  suture  in  bowel  union, 
529 


Davy's  lever,  injury  to  rectum  by,  568 
Deformities  of  oesophagus,  125 
Dermoid  tumours  of  intestine,  great, 

463 

rectum,  608,  610 

Diaphragmatic  hernia,  444,  481 
Diarrhoea   as  a  cause  of  prolapse  of 

rectum,  638 

—  —  of  ulceration  of  rectum,  581 

—  from  foreign  body  in  rectum,  575, 
576 

—  spurious  in  carcinoma  of  rectum, 
620 

Digital  examination  of  rectum,  565 

—  dilatation  of  pylorus,  267 
Dilatation,  digital,  of  pylorus,  267 

—  of  intestine,  great,  477 
small,  398,  414 

—  of  oesophagus,  112 

—  of  rectum,  592,  616 

—  of  stomach,  213,  224,  290 
Dilators,  tupelo  wood,  in  stenosis   of 

oesophagus,  97 
Diphtheria  as  a  cause  of  paralysis  of 

oesophagus,  104 
Diphtheritic  proctitis,  577 

—  ulceration  of  rectum,  581 
Distension  of  stomach  for  examination 

purposes,  154 
Distortion  of  oesophagus,  134 
Diverticula  of  intestine,  great,  483 

—  of  oesophagus,  117 

—  excision  of,  141 

—  of  rectum,  670 
Diverticulum  of  jejunum,  422 

—  Meckel's  varieties  of,  421 

—  result  of  stricture,  small  intestine, 
398 

—  of  stomach,  210 

—  strangulation  by,  356 

Douglas'  pouch,  drainage  of,  in  per- 
forated typhoid  ulcer,  346 

Drainage,  open,  in  perforated  gastric 
ulcer,  187 

—  of  peritoneal  cavity  in  perforated 
gastric  ulcer,  189 

Duodenectomy,  operation  of,  296 
Duodenoplasty,  operation  of,  296 
Duodenostomy,  operation  of,  295 

—  gastro-,  operation  of,  248 

—  in  carcinoma  of  stomach,  206,  208 

—  in  pyloric  obstruction,  215,  223 
Duodenotomy,  operation  of,  296 
Duodenum,  anatomy  of,  271 

—  carcinoma  of,  289 

• —  fibro-myxomata  of,  288 

—  foreign  bodies  of,  276 

—  injuries  of,  273 

—  obliteration  of,  293 

—  operations  on,  295 


INDEX   OF   SUBJECTS 


711 


Duodenum,  perforations  of,  280,  287, 
291 

—  rupture  of,  273 

—  sarcoma  of,  289 

—  stenosis  of,  291 

—  tumours  of,  288 

—  ulcer,  simple,  of,  277 

—  ulceration,  acute,  of,  284 
Dysenteric  proctitis,  578 

—  ulcer,  intestine,  great,  435 

—  ulceration  of  rectum,  581 
Dysentery  as  a  cause  of  stricture  of 

rectum,  591 


Ear  affections  in  spasm  of  oesophagus, 

107 
Egebert's  method  of  fixing  stomach  in 

gastrostomy,  232 
Electricity  in  treatment  of  paralysis  of 

oesophagus,  105 

of  spasm  of  oesophagus.  111 

Electrolysis  in  stricture  of  oesophagus, 

97 
of  rectum,  599,  693 

—  operation  of,  in  oesophageal  affec- 
tions, 136 

Embolic  appendicitis,  494 

Emesis  in  impacted  foreign  bodies  of 

oesophagus,  29 
Emphysema  in  traumatic  rupture  of 

ileum,  309 

—  in  oesophageal  perforation,  21 
Empyema  rupturing  into  oesophagus, 

133 

—  secondary  to  gastric  ulcer,  192 
Encephaloid  carcinoma  of  duodenum, 

289 

—  intestine,  great,  466 

—  oesophagus,  62 

—  rectum,  613,  615 

Endoscope,  electro-,  use  of,  in  impacted 

foreign  bodies  of  oesophagus,  24 
Enemata,  anthelmintic,  697 

—  astringent,  697 

—  in  appendicitis,  512 

—  in  carcinoma,  great  intestine,  471, 
476 

—  in  fffical  accumulation,  great  intes- 
tine, 460 

—  in  rectal  prolapse,  642 

—  in  rectal  stricture,  594,  622 

—  in  volvulus,  great  intestine,  451 

—  nutrient,  694 

—  purgative,  697 

—  sedative,  698 

—  uses  of,  677 

Enterectoniy,  operation  of,  526 
Enteric  variety  of  intussusception,  372 
Enteritis,  acute,  301 


Enteritis,  chronic,  301 

—  as  a  cause  of  intestinal  obstruction, 
420 

Entero-anastomosis,  methods  of,  527 
Entero-enterostomy,  operation  of,  543 
Enterolith  in  appendix,  496 
Entero-lithotomy,  operation  of,  406 
Enteroliths,  409,  453 
Enteroplasty,  operatioi    of,  543 

—  in  stenosis,  intestine,  great,  443 

small,  397,  401 

Enterostomy,  operation  of,  522 

—  gastro-,  operatioi   of,  248 
Enterotomy,  operation  of,  522 

—  in  obstructioi-  due  to  gall-stone, 
406 

Epilep.y  as  a  cause  of  spasm  of  oeso- 
phagus, 107 
Epithelioma  of  duodenum,  289 

—  of  intestine,  great,  465 
small,  412 

—  of  a-soiDhagus,  58 

extending  into  stomach,  207 

Erysipelatous  proctitis,  577 

Ewald's  method  of  obtaining  gastric 

juice  for  examination,  149 
Excision,  elliiDtical,  in  rectal  prolapse, 

644 

—  of  anus,  artificial,  556 

—  of  carcinoma,  great  intestine,  474 

—  of  diverticulum  of  oesophagus,  124 
of  rectum,  671 

—  of  gastric  ulcer  (non-perforated), 
179 

—  of  gastric  ulcer  (perforated),  185 

—  of  intestine  (enterectomy),  526 
— •  of  intussusception,  388 

—  of  obstruction,  gall-stone,  407 

—  of  pylorus,  260 

—  of  rectum,  624,  590 

• —  of  rupture,  intestine,  small,  311, 317, 
323 

—  of  sarcoma,  intestine,  small,  416 

—  of  stricture,  intestine,  small,  401, 
414 

—  —  rectum,  600 

—  of  tumour,  intestine,  419 

—  of  tubercular  disease,  intestine,  434 
— -  of  ulcer  of  rectum,  589 

—  of  volvulus,  392,  452 

Exostosis  of  vertebrae,  pressure  of,  on 
oesophagus,  132 

Extractors,  introduction  of,  in  affec- 
tions of  oesophagus,  134 


F.ECES,  character  of,  in  carcinoma  of 
rectum,  620 

of  sigmoid  flexure,  469,  471 

in  stricture  of  rectum,  593 


712 


SUEGERY  OF  THE  ALIMENTARY  CANAL 


Fspces,  incontinence  of,  after  proctec- 
tomy, 627 
Fallopian  tube  as  a  cause  of  intestinal 

strangulation,  356 
Fibromata  of  intestine,  great,  463 
small,  410 

—  of  cesophagus,  55 

—  of  rectum,  603,  610 

—  of  stomach,  201 

—  of  uterus,  giving  rise  to  intestinal 
obstruction,  418 

giving  rise  to  rectal  obstruction, 

674 
Fibro-myoma  of  intestine,  great,  463 

of  stomach,  201 

Fibro-myxoma  of  duodenum,  288 
Fistula,  bimucous,   in  gastro-entero- 

stomy,  260 

—  fffical,  in  appendicitis,  514 

■ —  —  in  dilatation,  intestinal,  480 

—  —  in  gall-stone  obstruction,  407 

—  —  intussusception,  388 

—  —  in  stricture,  intestinal,  398,  401, 
414 

rectal,  670 

in  ulcer,  duodenal,  281 

in  wounds,  gunshot,  322 

closure  of,  555 

—  from  foreign  body  in  rectum,  575 

—  gastric,  in  gastro-enterostomy,  259 

in  ulcer,  gastric,  187,  196 

in  wounds,  gunshot,  164 

treatment  of,  160 

in  ano  in  carcinoma,  rectal,  617 

recto-vesical    in    carcinoma   of 

rectum,  617,  634 

umbilical,  relation  of,  to  perma- 
nence of  vitelline  duct,  421 

Fixation  of  bowel  in  sigmoid  anus, 
551 

Follicles,  lymphoid,  of  rectum,  563, 
606 

—  simple,  of  intestine,  great,  428 

—  solitary  lymph,  in  appendix,  491 
Follicular  colitis,  438 

—  oesophagitis,  46 

Foramen  of  Winslow,  hernia  into,  350 
Forceps,  introduction  of,  in  cesopha- 
geal  affections,  134 

—  use  of,  inasophageal  affections,  32 
Foreipn  bodies  in  appendix,  49(5 
in  duodenum,  276 

in  intestine,  great,  328 

in  intestine,  small,  328 

in  oesophagus,  16 

—  —  —  as  a  cause  of  diverticula,  119 
iir  rectum,  571 

■ as  a  cause  of  proctitis,  573, 

577 
of  stricture,  591 


Foreign  bodies  in  rectum  as  a  cause 

of  ulceration,  581 

in  stomach,  164 

Fossa,  duodeno-jejunal,  hernia   into, 

350 

—  intersigmoid,  hernia  into,  350 

—  pericffical,  hernia  into,  350 
Frank's  modification  of  gastrostomy, 

244 
Fungous     carcinoma    of    duodenum, 
289 


Gall-bladdeb,  distension  of,  in  malig- 
nant disease,  duodenum,  290 

causing  pyloric  obstruction,  209 

Gall-stone  in  appendix,  496 

—  ulcerating  into  stomach,  210 
Gall-stones,  obstruction  of  great  intes- 
tine by,  453 

of  small  intestine  by,  401 

—  stenosis  of  duodenum  due  to,  292 

—  volvulus  due  to,  390 
Gangrene  of  appendix,  493 

—  of  intestine,  small,  from  contusion, 
302 

Gastrectasia,  156 
Gastrectomy,  operation  of,  244 
Gastric  fistula  (see  Fistula) 

—  juice,  method  of  obtaining  for 
examination,  149 

method    of    detection     of    free 

hydrochloric  acid,  151 

method  of  determining  rate  of 

absorption,  151 

variability  of  digestive  proper- 
ties, 292 

—  ulcer  {see  Ulcer),  176 

diagnosis    from   varix   of    ceso- 
phagus, 50 
Gastritis,  acute,  157 
Gastro-anastomosis,  200 
Gastro-colostomy,  248 
Gastrodiaphany,  155 
Gastro-enterostomy,  operation  of,  248 

—  combined  with  jDylorectomy,  265 

—  in  pyloric  obstruction,  215,  220 
Gastro-ileostomy,  248 
Gastro-jejunostomy,  248 
Gastroliths,  172 

Gastropexy,  operation  of,  248 

—  reference  to,  225 
Gastroplication,  248 
Gastroptosis,  156,  248 
Gastrorrhaphy,  operation  of,  247 

—  in  a  case  of  dilatation  of  stomach, 
225 

Gastroscopy,  155 
Gastrostomy,  operation  of,  232 
Frank's,  244 


INDEX   OF  SUBJECTS 


713 


Gastrostomy,  operation  of,  Von  Hac- 
ker's, 240 

—  —  Halm's,  241 

• Witzel's,  242 

—  in  atresia  of  ctsophagus,  127 

—  in  carcinoma  of  oesophagus,  74,  78, 
81,  82 

—  in  diverticula  of  oesophagus,  123 

—  in  pj'loric  obstruction,  215,  223 

—  in  stricture  of  oesophagus,  95,  102 
Gastrotomy,  operation  of,  230 

• —  —  for  extraction  of  foreign  bodies, 

stomach,  171 
—  oesophagus,  35 

—  in  oesophageal  stenosis,  97 
Gersuny's    tubage    in    carcinoma    of 

oesophagus,  77 
Glands,  Briinner's,  272,  298 
■ —  lumbar,  in   carcinoma  of   rectum, 

018,  G21,  634 
■ —  mesenteric,  causing  pyloric  obstruc- 
tion, 209 

in  carcinoma,  great  intestine,  469 

in  sarcoma,  intestinal,  416,  418 

tubercular,    dragging    stomach, 

227 

—  pressing  on  oesophagus,  131 

—  retro-peritoneal  pressing  on  duo- 
denum, 290 

—  sacral,  in  carcinoma  of  rectum,  618, 
621,  634 

—  solitary,  273,  299,  428 
in  tubercular  ulcer,  339 

—  —  in  typhoid  ulcer,  341 

—  supraclavicular,  in  carcinoma  of 
stomach,  204 

Glenard's  disease,  227 

Gluteus  maxiraus,  fibres  of,  as  a 
sphincter  in  proctectomy,  690 

Goitre  causing  pressure  on  oesophagus, 
132 

Gonorrhoea  as  a  cause  of  ulceration  of 
rectum,  581 

Gonorrhoeal  proctitis,  577 

Gout  as  a  cause  of  spasm  of  oesopha- 
gus, 107, 111 

of  stricture  of  oesophagus,  89 

Gunshot  wounds,  intestinal,  319 

Giinzburg's  method  for  detection  of 
free  hydrochloric  acid  in  gastric 
juice,  151 

Hackee's,  Von,  operation  of  gastro- 
stomy, 240 

Haemorrhage  after  gastro-entero- 
stomy,  259 

—  after  lavage  of  stomach,  229 

—  in  angeiomata  of  rectum,  608 

—  in  appendicitis  (from  iliac  vessels), 
493 


Hfemorrhage  in  carcinoma,  duodenum, 
290 

—  —  rectum,  620 

sigmoid  flexure,  409,  471 

stomach,  204 

—  in  duodenal  ulcer,  279 

—  in  dysenteric  ulcer,  435 

—  in  gastric  ulcer,  180 

—  in  injury,  rectal,  569,  573 
in  intra-abdominal,  306,  316 

—  in  intussusception,  cause  of,  376, 
396 

colic,  448 

—  in  papilloma,  great  intestine,  462 

—  —  rectum,  605,  610 

—  in  proctitis,  578 

—  in  prolapse  of  rectum,  640 

—  in  thrombosis,  mesenteric  vessels, 
487 

Hemorrhoids,  as  a  cause  of  prolapse 
of  rectum,  638 

—  in  carcinoma  of  rectum,  618 
Hahn's    operation     of     gastrostomy, 

241 
Hair  tumours  of  stomach,  172 
Halsted's  suture  in  bowel  union,  535 
Heart,  enlarged  auricles  of,  pressing 

on  oesophagus,  131 

—  injury  to,  from  fish  bone  in  oeso- 
phagus, 22 

—  pressure  on,  in  fsecal  accumulation, 
456 

in  dilatation  of  colon,  478 

Hegar's  method  of  proctectomy,  686 
Heineke's  method  of  proctectomy,  685 

—  Mikulicz,  pyloroplasty,  215,  265 
Hepatic  colic,  sunulating  appendicitis, 

503 
Hernia,   internal,  of  great   intestine, 
444 

—  of  small  intestine,  350 

diagnosis  of,  361 

symptoms  of,  358 

treatment  of,  362 

—  rectal,  654 

—  reduced  and  causing  stricture,  395, 
397 

Hiccough,  persistent,  after  gastro- 
enterostomy, 258 

Hour-glass  contraction  of  stomach, 
200 

Houston's  folds  of  rectum,  563 

Humerus,  involvement  of,  in  carci- 
noma of  rectum,  619 

Hydatid  cyst  causing  pyloric  obstruc- 
tion, 209 

—  of  meso-colon  (rectal),  causing 
obstruction,  676 

Hydrochloric  acid,  absence  of  free,  in 
carcinoma  of  stomach,  203,  213  "  ■ 


714 


SURGERY  OF  THE  ALIMENTARY  CANAL 


Hydrochloric  acid,  administration  of, 

in  a  case  where  razor  was  swallowed, 

168,  171 
—  detection    in     gastric     juice     (see 

Gastric),  151 
Hydrogen  gas,  inflation  of  bowel  by,  322 
Hysteria,    spasm    of    oesophagus    in, 

107 


Idiopathic  oesophagitis,  acute,  38 
Ileo-cascal  valve,  429 

—  abnormalities  of,  485 

—  cystic  dilatation  of,  464 

—  orifice  constricted  as  a  cause  of 
intussusception,  375 

Ileo-colostomy,  operation  of,  543 

—  in  carcinoma  of  great  intestine, 
476 

Ileo-ileostomy,  operation  of,  543 
Ileostomy,  operation  of,  525 

—  in  carcinoma  of  great  intestine, 
476 

Ileotomy,  operation  of,  522 
Ileum  {see  Intestine,  small) 
- —  fistulous   communication  between 
colon  and,  467 

—  opened  instead  of  jejunum  in  gastro- 
enterostomy, 260 

Ileus  paralyticus,  458 

Iliac  vein,  thrombosis  of,  in  appendi- 
citis, 493 

Impacted  foreign  bodies,  oesophagus, 
16 

Impaction,  faecal,  rectum,  572 

Inanition  after  gastro-enterostomy, 
259 

Inflation  in  intussusception,  383 

—  of  stomach  for  examination  pur- 
poses, 154 

Inguinal  colostomy,  546 
Injection  in  intussusception,  384 
Injuries  of  duodenum,  273 

—  intestine,  great,  430 
• small,  300 

—  rectum,  567 

—  stomach,  156 

Innervation,  irregular,  as  a  cause  of 

intussusception,  375 
Intestinal  neuroses,  424 

—  obstruction  {see  Intestine) 

—  after  gastro-enterostomy,  259 
Intestine,  great,  abnormalities  of,  480 

accumulation,  fftcal,  of,  455 

adenoma  of,  462 

anatomj-  of,  425 

—  —  carcinoma  of,  464 

—  —  contusions  of,  430 

cysts  of,  464 

dermoids  of,  463 


Intestine,  great,  dilatation,  congenital, 
478 

fibroma  of,  463 

fibro-myoma  of,  463 

foreign  bodies  of,  328 

idiopathic,  dilatation  of,  477 

inflammation  of,  431 

—  • —  injuries  of,  430 
intussusception  of,  447 

—  —  kinking  of,  446 

—  —  lipoma  of,  463 

— •  ^  maldevelopment  of,  483 

misplacement  of,  481 

nerve  supply  of,  429 

papilloma  of,  462 

perforation  of,  617 

physiology  of,  430 

—  —  rupture,  traumatic,  of,  480 

—  —  sarcoma  of,  476 

—  ■ —  strangulation,  internal,  of,  444 

—  —  stricture,  cicatricial,  of,  438 
— .  —  structure  of,  427 

—  —  tumours  of,  461 

—  —  ulceration  of,  431 

—  —  vascular  supply  of,  428 
volvulus  of,  449 

—  —  wounds  of,  313 
_ gunshot,  319 

Intestine,  small,  abnormalities  of,  421 

—  —  adenomata  of,  411 
anatomy  of,  297 

—  —  carcinoma  of,  412 
contusions  of,  300 

—  —  cysts  of,  411 

—  —  diverticulum  of  jejunum,  422 

—  —  diverticulum,  Meckel's,  421,  356 

—  —  diverticulum  from  stricture,  398 

—  —  enteroliths,  409 

—  —  epithelioma  of,  412 

—  —  fibromata  of,  410 

—  -^  foreign  bodies  of,  328 
gall  stones  in,  401 

hernia,  internal,  of  {see  Hernia), 

350 
imperforate,  422 

—  —  inflammation  of,  301 

—  —  injuries  of,  300 

—  —  intussusception,  371 
kinking  of,  368 

—  —  lipoma  of,  411 

lymphadenoma  of,  416 

—  —  lymphatic  system  of,  299 

—  —  lymphoma  of,  416 
malformations  of,  421 

Meckel's  diverticulum  {see  Diver- 
ticulum) 

myomata  of,  410 

nerve  supply  of,  299 

obstruction  of,  349 

occlusion,  membranous,  of,  421 


INDEX   OF   SUBJECTS 


715 


Intestine,  small,  operations  on,  522 

physiology  of,  300 

•- polypi  of,  410,  414 

rupture  of,  805 

sarcoma  of,  414 

sloughing  of,  302 

—  — ■  stricture,  cicatricial,  of,  393 
- — congenital,  421 

structure  of,  297 

transposition  of,  422 

tumours  of,  410 

ulceration  of,  302,  339,  341 

vascular  supply  of,  299 

vitelline  duct  of,  421 

volvulus  of,  389 

wounds  of,  313 

gunshot,  319 

Intussusception    of    intestine,   great, 
447 

—  small,  371 

—  —  anatomy,  pathological,  of,  372 
causes  of,  374 

symptoms  of,  379 

treatment  of,  382 

varieties  of,  372 

—  of  rectum,  653 

in  carcinoma,  618 

of  polypi,  611 

Iron    sulphate    in    rectal     prolapse, 
641 


Jaundice   in    malignant    disease     of 

duodenum,  290 
Jejuno-ileostomy,  operation  of,  543 
Jejuno-jejunostomy,  543 
Jejunostomy,  operation  of,  523 

—  gastro-,  operation  of,  248 

—  in  carcinoma  of  stomach,  206 

—  in  pyloric  obstruction,  215,  228 
Jejunotomy,  operation  of,  522 
Jejunum,  affections  of   (see  Small  in- 
testine) 

Jessett's  fixation  of  stomach  in  gastro- 
enterostomy, 236 

—  modification  of  jejunostomy,  523 


Kidney,  displaced,  as  a  cause  of  faecal 

accumulation,  459 
Kinking,  causing  strangulation,  great 

intestine,  446 

small  intestine,  368 

Kleberg's  operation  in  rectal  prolapse, 

648 
Kocher's     method    of     proctectomy, 

685 
Kraske's    operation    of    proctectomy, 

683 
—  case  of,  634 


Laminar  carcinoma  of  rectum,  613 

Larainaria,  in  malignant  stricture  of 
oesophagus,  78 

Lange's  operation  in  rectal  prolapse, 
652 

Lavage  of  stomach,  215,  223 

Laparotomy  (see  under  different 
affections) 

Larynx,  affections  of,  as  a  cause  of 
spasm  of  oesophagus,  107 

Laryngeal  recurrent  nerve,  in  carci- 
noma of  oesophagus,  66,  71 

Lead  poisoning  as  a  cause  of  paralysis 
of  oesophagus,  104 

Leube's  meat  emulsion  in  rectal  ali- 
mentation, 694 

Levy's  method  of  proctectomy,  685 

Lieberkiihn,  crypts  of,  in  intestine, 
298 

in  rectum,  563 

relation  to  adenomata,  411 

Ligament,  gastro- phrenic  and  gastro- 
splenic,  relation  to  stomach,  145 

Lipomata  of  intestine,  great,  463 

—  small,  411 

—  of  mesentery  as  a  cause  of  volvulus, 
390 

—  of  oesophagus,  51 

—  of  rectum,  607 

—  of  stomach,  201 
Lipo-myomata  of  stomach,  201 
Lithotomy,  injury  to  rectum  in,  568 
Liver,   abcesses    of,   in    appendicitis, 

494,  501 

—  affections  of,  giving  rise  to  pyloric 
obstruction,  209 

carcinoma  great  intestine,  468 

—  dulness,  in  rupture,  small  intestine, 
308 

—  involvement  of,  in  carcinoma,  great 
intestine,  469 

—  —  in  carcinoma  of  rectum,  618 
621,  634 

Loreta's  digital  dilatation  of  pylorus, 
operation  of,  267 

—  references  to,  215,  222 
Lumbar  anus,  formation  of,  554 
— •  colostomy,  operation  of,  544 
Lungs,  involvement  of,  in  carcinoma 

of  rectum,  618 
Lym^Dhadenoids  of  stomach,  201 
Lymphadenoma,  great  intestine,  477 

—  small  intestine,  416 
Lymphatic  system  of  great  intestine, 

428 

—  of  small  intestine,  299 

—  of  rectum,  564 

Lymphoma  of  small  intestine,  416 

—  of  oesophagus,  84 

—  of  rectum,  606 


716 


SURGERY  OF  THE  ALIMENTARY  CANAL 


Lympho-sarcoma  of  duodenum,  289 

—  of  oesophagus,  84 

—  of  neighbouring  organs  pressing 
on  oesophagus,  132 

—  of  stomach,  206 

Magnesia,  mass  of,  giving  rise  to  in- 
testinal obstruction,  409 

Maisonneuve's  urethrotome  in  oeso- 
phageal stenosis,  101 

Malformations  of  great  intestine,  483 

—  of  small  intestine,  420 
. —  of  oesophagus,  125 

—  of  rectum,  654 

Manipulation  in  treatment  of  oesopha- 
geal impacted  foreign  body,  28 

Massage  in  ftecal  accumulation,  460 

in  volvulus  (early),  451 

Maunsell's  method  of  proctectomy, 
692 

—  suture  in  bowel  union,  532 
Maydl's  modification  of  jejunostomy, 

524 

Mayet's  meat  emulsion  in  rectal  ali- 
mentation, 694 

McBurney's  point  in  appendicitis,  500 

McLeod's  operation  in  rectal  prolapse, 
651 

Meckel's  diverticulum  {see  Diverticu- 
lum), 421 

Medulla,  involvement  of,  in  paralysis 
of  oesophagus,  103 

Medullary  carcinoma  of  intestine, 
great,  465 

—  of  oesophagus,  62 

—  of  rectum,  613 

—  of  stomach,  203 

Meljena  in  duodenal  ulcer,  279 
Melanotic  carcinoma  of  rectum,  615 

—  sarcoma  of  rectum,  636 
Membranous  oesophagitis,  42 
Mesenteric     vessels,    embolism     and 

thrombosis  of,  486 
Mesentery,  extra  length  of,  as  a  cause 
of  volvulus,  389 

—  injury  to,  306,  312,  316 

. —  in  intussusception,  372,  376 

—  involvement  of,  in  sarcoma  of  small 
intestine,  415 

—  strangulation  by,  357 

• —  strangulation  through  rent  in,  352, 

444 
Meso-appendix,  490 

—  colon,  426 

in  volvulus,  449,  452 

—  rectum,  561 
hydatid  of,  676 

—  sigmoid,  427 

Meteorism,  in  acute  obstruction  from 
stricture,  400 


Meteorism,  in  internal  strangulation 
360 

Micturition,  difficulty  of,  in  rectal  pro- 
lapse, 640 

—  frequency  of,  in  rectal  irritation, 
573,  578 

Mikulicz's  operation  in  rectal  prolapse, 

646 
Misplacement  of  great  intestine,  481 
Mucus,  discharge  of,  in  rectal  polypus, 

609 
Murphy's  button,  description  of,  256 

—  in  intestinal  anastomosis,  401,  419 
'  Musculus    ijleuro-broncho     oesopha- 
gus '  as  a  cause  of  diverticula,  119 

Myomata  of  small  intestine,  410 

—  causing  pyloric  obstruction,  210 

—  of  oesophagus,  55 

—  of  rectum,  6Q6 

—  of  stomach,  201 
Myxomata  of  oesophagus,  55 

—  of  rectum,  607 

N^vi  of  rectum,  608 
Naphthol   in    carcinoma   of    rectum, 
631 

—  use  of,  before  proctectomy,  680 
Needles,  effects  produced  by  wander- 
ing, 338 

N^laton's  operation  of  enterostomy, 
522 

Nephritic  colic  simulating  appendi- 
citis, 503 

Nerve  supply  of  great  intestine,  429 

of  small  intestine,  299 

of  oesophagus,  3 

of  rectum,  564 

of  stomach,  147 

Neuralgia  of  rectum,  672 

Neuroses,  intestinal,  425 

—  rectal,  672 

Nomenclature  of  operations  on  in- 
testines, 518 

Nose,  affections  of,  as  a  cause  of  spasm 
of  oesophagus,  107 

Obliteration,  complete,  of  duodenum, 

293 
Obstruction,  cardiac,  of  stomach,  207 

—  duodenal,  from  malignant  tumour, 
290 

—  intestinal  acute,  from  accumulation, 
fascal,  458  ^ 

fi'om  appendicitis,  500,  503 

from  carcinoma  of  great  in- 
testine, 468 

of  rectum,  616,  617,  621,  634 

from    foreign    body,   intestinal, 

330, 336 
rectal,  575 


INDEX    OF   SUBJECTS 


717 


Obstruction,    intestinal   acute,     from 
gall-stone,  401 

after  gastro-enterostoiiiy,  259 

from  hernia,  internal,  850 

—  —  from  intussusception,  371,  447 
from  peritonit's,  419 

from  pressure  from  without,  417 

simulating  appendicitis,  504 

from  stricture,  cicatricial,  393, 

438 

rectal,  594 

thrombosis  of  iliac    vessels, 

486 

tumours,  410 

volvulus,  389,  449 

—  intestinal,  chronic,  as   a  cause  of 
ulceration,  436 

rectal,  from  tumours,  609 

—  pyloric,  of  stomach,  208 
Occlusion,  membranous,  of   jejunum, 

421 
Esophagectomy,  operation  of,  142 
(Esophagismus,  106 
CEsophagitis,  acute  traumatic,  37 

—  acute  idiopathic,  38 

—  aphthous,  44 

—  catarrhal,  46 

—  of  children,  40 

—  chronic,  44 

—  croupous,  46 

—  follicular,  42 

—  membranous  or  pellicular,  42 

—  phlegmonous,  46 
Qi^sophagoplasty,  operation  of,  142 
(Esophagoscope,  50,  69,  80 
0''.sophagoscopy,  28 
QEsophagostomy,  operation  of,  140 

—  external,  in  stenosis,  99,  102 

—  internal,  in  carcinoma  of  cesophagus, 
78,  81 

in  stenosis,  98,  102 

(Esophagotome,  98,  136 
CEsophagotomy,  external,  operation  of 

(cervical),  137 
(thoracic),  139 

—  internal,  oi^eration  of,  136 

in  removal  of  foreign  bodies,  32, 

34 
(Esophagus,  abnormalities  of,  112 

—  anatomy,  surgica',  of,  1 

—  atresia,  congenital,  of,  126 

—  attachments  of,  2 

—  calibre  of,  3 

—  carcinoma  of,  58 

—  course  and  extent  of,  1 

—  •  cysts  of,  55 

— -  dilatation  of,  112 

—  distortion  of,  134 

—  diverticulum  of,  117 

—  foreign  bodies  impacted  in,  16 


CF^sophaguB,  injuries  of,  4 

—  malformation  of,  125 

—  operations  on,  134 

—  paralysis  of,  103 

—  perforation  of,  133 

—  physiology  of,  4 

—  pressure  from  without  affecting, 
131 

—  relations  of,  2 

—  rupture  of,  10 

—  sarcoma  of,  84 

—  spasm  of,  106 

—  stricture  of,  84 
— ■  —  malignant,  58 

—  structure  of,  3 

—  syphilis  of,  52 

—  torsion  of,  130 

—  tuberculosis  of,  52 

—  ulcer  of,  46 

—  varix  of,  49 

—  warts  of,  54 

Omentum,  affections  of,  giving  rise  to 
pyloric  obstruction,  209 

—  gastro-hepatic,  in  relation  to 
stomach,  145 

—  great,  145 

—  strangulation,  intestinal,  by,  357 
Opium,  in  carcinoma  of  rectum,  (i32 
Ovarian   tumours,   causing   intestinal 

obstruction,  418 

Ovariotomy,  intestinal  obstruction 
after,  370 

Ovary,  adhesion  of  vermiform  appen- 
dix to,  444 


Pain  in  appendicitis,  498 

—  in  carcinoma    of   intestine,    great, 
469, 471 

of  rectum,  616,  620 

— relief  of,  632 

—  in  duodenal  ulcer,  278 

—  in  injuries,  rectal,  569,  573 

—  in  intussusception,  380,  381 

—  in  obstruction  due  to  gaP-stone,  403 
pressure  from  without,  419 

—  in  papilloma  of  rectum,  462 

—  in  periproctitis,  581 

—  in  jjeritonit's,  420 

—  in  j^roctitis,  578 

—  in  prolapse,  rectal,  640 

—  in    rupture,  traumatic   (intestinal), 
308 

—  in  strangulation,  internal,  359 

—  in  stricture,  cicatricial  (intestinal), 
395,  440 

—  (rectal),  594 

—  in  thrombosis  of  mesenteric  vessels, 
486 

—  in  ulcer,  gastric,  178 


•18 


SURGERY    OF   THE   ALIMENTARY   CANAL 


Pain  in  ulceration  of  rectum,  587 

—  in  volvulus,  391,  451 

—  in  wounds,  315 
_  —  gunshot,  320 

—  after  gaatro-enterostoiny,  258 
Pancreas,  affections  of,  giving  rise  to 

pyloric  obstruction,  209 

—  tumours  of,  pressing  on  duodenum, 
289 

Panelectroscope  in  impacted    foreign 
bodies  of  oesophagus,  24 

—  in  rectal  examination,  567 
Papillomata,  intestinal,  462 

—  as  a  cause  of  intussusception,  447 

—  of  oesophagus,  54 

—  of  rectum,  603 

—  of  stomach,  202 
Paralysis  of  oesophagus,  103 

—  —  due  to  syphilis,  52 

as  a  cause  of  dilatation,  113 

Parasacral    method    of    proctectomy, 

687 
Parietes,     abdominal     injury    to,   in 

wounds  of  abdomen,  314 
Parturition  as  a  cause  of  stricture  of 

rectum,  591 

of  ulceration  of  rectum,  586 

Pathology  of  appendicitis,  492 

—  of  atresia  of  oesophagus,  126 

—  of  carcinoma,  intestinal,  465,  412 

—  —  — -  rectal,  613 

—  of  diverticula  of  oesophagus,  120 

—  of  intussusception,  372 
Paul's  operation  of  colectomy,  547 
Pellicular  oesophagitis,  42 

Pelvis,  laceration  of  rectum  in  fracture 

of,  666 
• —  lack  of  development  of,  in  atresia 

recti,  659 
Penis,  rectum  terminating  in,  658,  661 
Perforation,  duodenal,  from   external 

causes,  294 
— -  • —  from  malignant  disease,  291 

from  ulcer,  280 

from  ulceration,  287 

—  intestinal    (great  intestine)    in  ap- 
pendicitis, 493,  502 

treatment  of,  515 

from  carcinoma,  467, 470,617 

— from  dilatation,  479 

— .  —  —  in  thrombosis  of  mesenteric 

vessels,  487 
from  ulcer,  432,  435 

—  intestinal    (small  intestine),    from 
foreign  body,  330 

in  intussusception,  331 

— several     with    no    serious 

symptoms,  820 
—  several    successfully   closed, 

323,  327 


Perforation,  intestinal  (small  intes- 
tine), in  stricture,  398 

— in  typhoid,  342 

in     ulceration,      tubercular, 

341 

—  oesophageal,  by  foreign  body,  20 

from  external  causes,  133 

from  pressure  of  aneurysm,  131 

from  ulceration  of  sarcoma,  83 

—  rectal,  from  foreign  body,  575 
— >  —  from  carcinoma,  621 
from  ulceration.  582 

—  of  stomach,  from  foreign  body,  167 
following  lavage,  229 

in  malignant  disease,  203,  205 

—  _  of  ulcer  (subject),  181,  188,  190 
Pericarditis  secondary  to  gastric  ulcer, 

192, 194 
Pericardium,   distended,   pressing   on 

oesophagus,  131 
Perineal  proctectomy,  681 

prognosis  of,  625 

Periproctitis,  580 

—  as  a  cause  of  stricture,  590 

—  in  congenital  rectal  stricture,  670 
Peristalsis,   violent,    as    a    cause    of 

volvulus,  450 

Peritonitis  (intestine,  great),  in  appen- 
dicitis, 502,  508 

treatment  of,  515 

—  —  —  in  carcinoma,  467 

— in  stricture,  cicatricial,  441 

—  in  ulcer,  432,  435,  437,  456 

in  volvulus,  450 

—  (intestine  small,  duodenum),  in 
duodenal  perforation,  281,  290 

• in  duodenal  rupture,  274 

—  (jejunum  and  ileum),  from  foreign 
body,  330 

from  gall-stone,  403 

from  intussusception,  381 

— from  strangulation,  internal, 

360 

■  —  from  stricture,  399 

from  ulceration,    traumatic, 

303 

tubercular,  339 

—  typhoid,  341 

wounds,  316 

gunshot,  322 

—  (rectal),  from  foreign  body,  575 

—  —  from  stricture,  592,  594 

—  (stomach),  from  perforated  ulcer, 
182 

after    gastro-ehterostomy,    259, 

264 

—  symptoms  of,  420 

tubercular,    giving   rise   to   in- 
ternal strangulation,  368 
Pessary  in  rectal  prolapse,  641 


INDEX   OF   STT.JI'riS 


719 


Petersen's  bag,  rupture  of  rectum  by, 

568 
Peyer's  patches,  273,  2t)9 

in  tubercular  ulceration,  339 

• in  typhoid  ulceration,  341 

Phantom  stricture  of  rectum,  672 
Pharyngeal  diverticula,  IIB 
Phimosis  as  a  cause  of  rectal  prolapse, 

638 
Phlebectasis  of  oesophagus,  49 
Phlebitis  of  iliac  vein  in  appendicitis, 

493 
Phlegmonous  oesophagitis,  46 
Photography,  new,  in  impacted  foreign 

body  of  oesophagus,  24 
Physical    examination    of     stomach, 

153 
Physiognomy  of  internal  strangulation, 

360 
Physiology  of  great  intestine,  430 

—  of  small  intestine,  300 

—  of  oesophagus,  4 

—  of  rectum,  564 

—  of  stomach,  147 

Plates  for  intestinal  anastomosis  of 
Baracz  (cabbage,  turnip),  255 

—  of  Dawbarn  (potato),  255,  538 

—  of  Eobinson  (raw  hide),  257,  538 
- —  of  Senn  (bone),  253,  535 

Plastic  operation  in  congenital  umbili- 
cal fistula,  424 

Pleurisy  secondary  to  gastric  ulcer, 
192 

Pneumonia  after  gastro -enterostomy, 
260 

—  secondary  to  gastric  ulcer,  192 
Poisoning  following  lavage  of  stomach, 

229 

—  irritant,  effects  of,  as  a  cause  of 
pyloric  obstruction,  210,  214 

—  treated  by  aspiration  of  stomach, 
230 

Polypi  of  great  intestine,  462 

—  of  small  intestine,  410 

—  —  as  a  cause  of  intussusception, 
374 

sarcomatous,  414 

—  of  oesophagus,  55 

—  of  rectum,  602,  609 

—  —  as  a  cause  of  proctitis,  577 
prolapse,  611,  638 

—  —  —  ulceration,  581 

Pons,  involvement  of,  in  paralysis  of 

oesophagus,  104 
Pouches  of  stomach,  202 
Probang  in  impacted  foreign  bodies  of 

oesophagus,  31 
■ —  introduction  of,  134 
Procidentia  recti,  637 
Proctectomy,  operation  of,  680 


Proctectomy,  perineal,  681 

—  sacral,  083 

—  vaginal,  691 
Proctitis,  acute,  577 

—  chronic,  578 

as  a  cause  of  stricture,  590 

Proctopexy,  operation  of,  693 

—  in  rectal  prolapse,  652 
Proctoplasty,  operation  of,  693 
Proctorrhaphy,    operation      of,    643, 

692 
Proctotomy,  external, operation  of,  633, 
679 

—  —  in  stricture,  600 

—  internal,  678 

—  —  in  stricture,  599 

Prolapse  of   bowel  in  sigmoid   anus, 
533 

—  of  rectum,  637 

—  —  causes,  638 

symptoms,  639 

treatment,  640 

Prolapsus  ani,  637 

Prostate  enlarged  in   rectal  prolapse, 

638 
Prostatic  abscess  pressing  on  rectum, 

675 
Psoas     muscle,    involvement    of,    in 

appendicitis,  501 
Pulse  in  appendicitis,  499 

—  in  rupture,  traumatic,  small  intes- 
tine, 308 

—  in  internal  strangulation,  360 

—  in  wounds,  gunshot,  320 
Purgatives  as  a  cause  of  proctitis,  577, 

580 

—  —  rectal  ulceration,  581 
Pyasmia  in  appendicitis,  494,  501 

—  in  carcinoma    of    great    intestine, 
468 

—  secondary  to  impacted  fish-bone  in 
oesophagus,  21 

Pylorectomy,  operation  of,  260 

—  references  to,  215,  218,  220 

—  combined  with  gastro-enterostomy 
265 

Pyloroplasty,  operation  of,  265 

—  references  to,  215,  222 
Pylorus,  carcinoma  of,  209 

—  curettage  of  (Bernay's),  268 

—  divulsion    digital    (Loreta's),    215, 
222 

—  excision  of  (operation),  260 

—  —  (reference),  220 

—  kink  of,  209 

—  position  of,  145 

—  stenosis  of,  208 

—  ^  secondary  to  gastric  ulcer,  200 
Pyo-pneumothorax,  subphrenic,  secon- 
dary to  gastric  ulcer,  194 


720 


SURGERY  OF  THE  ALIMENTARY  CANAL 


Eectal  alimentation,  693 

—  cauterisation,  643,  693 

—  electrolysis,  599,  693 
Eectocele,  654 

Eectopexy  in  rectal  prolapse,  652 
Rectostomia   glutealis   of    Witzel    in 

proctectomy,  690 
Eectum,  adenomata  of,  602 

—  anatomy  of,  561 

—  angeiomata  of,  608 

—  atresia  of,  665 

—  carcinomata  of,  612 

—  concretions  of,  573 
■ —  cystomata  of,  607 

—  dermoids  of,  608 

—  diverticula  of,  670 

—  examination  of,  566 

—  external  influences  on,  673 

—  fibromata  of,  603 

—  fistulous   communication   between 
appendix,  493 

—  foreign  bodies  of,  571 

—  hernia  of,  654 

—  impaction  of  ffeces  in,  572 

—  inflammation  of,  577 

—  injuries  of,  567 

■ — ■  intussusception  of,  653 

—  lipomata  of,  607 

—  lymphatics  of,  564 

—  lymphomata,  606 

—  malformations  of,  654 

—  myomata  of,  606 

—  myxomata  of,  607 

—  nsevi  of,  608 

—  nerve  supply  of,  564 

—  neuralgia  of,  672 
— ■  neuroses  of,  672 

—  operations  on,  676 

—  papillomata  of,  603 

—  physiology  of,  564 

—  polypi  of,  602 
multiple,  605 

—  prolapse  of,  637 

—  relations  of,  562 

—  rupture  of,  568 

—  sarcoma  of,  686 

—  stricture,  cicatricial,  of,  590 
congenital,  669 

phantom,  672 

—  structure  of,  562 

—  teratomata  of,  608 

—  tumours  of,  601 

—  ulceration  of,  581 

—  vascular  supply  of,  563 

—  wounds  of,  567,  569 

Eehn's      method      of      proctectomy, 

686 
Eehn-Eydygier  method  of  proctectomy, 

686 
Eelapsing  appendicitis,  494,  502 


Eegurgitation  of  bowel  contents  into 

stomach  after    gastro-enterostomy, 

258 
Eennie's   peptonised   meat  in    rectal 

alimentation,  695 
Eesection  of  bowel  in  intussusception, 

387,  389 
in  internal  strangulation,  365 

—  of  cardiac  orifice  of  stomach  (see 
Excision),  208 

Eespiration,  embarrassment  of,  infrecal 
accumulation,  456 

—  in  traumatic  rupture  of  small  in- 
testine, 308 

Eheumatisin  in  relation  to  appen- 
dicitis, 497 

— ^  as  a  cause  of  stricture  of  oesophagus, 
89       _ 

Ring  stricture  of  great  intestine,  466 

Rings,  catgut,  in  bowel  union,  542 

Roberts'  operation  in  rectal  prolapse, 
644 

Ruminants,  condition  in,  as  compared 
with  diverticula  of  oesophagus,  117 

Rupture  of  cscurn,  617 

—  of  duodenum,  173 

—  of  intestine,  great,  430,  442,  457 
small,  305 

—  from  inflation  in  intussusception, 
384 

—  result  of  tapeworm,  339 

—  of  oesophagus,  10 

—  of  rectum,  640,  662 

—  of  stomach,  157 

— •  —  following  lavage,  229 


Sacral   plexus,  pressure  on,   in  car- 
cinoma of  rectum,  616 

—  proctectomy,  683 
prognosis  of,  627 

Sarcinas     ventriculi,  causing    pyloric 

obstruction,  166 
Sarcoma  of  duodenum,  289 

—  of  great  intestine,  476 

—  of  small  intestine,  414 

—  of  oesophagus,  82 

—  of  other  organs  pressing  on  oeso- 
phagus, 132 

—  of  pylorus,  209 

—  of  rectum,  636 

—  of  stomach,  206 

Sauropsida,  condition  of,  and  as  found 

in  diverticula  of  oesophagus,  117 
Scalds  of  oesophagus,  4 
Scirrhous  carcinoma  of  duodenum,  289 

—  carcinoma  of  intestine,  465 

—  —  of  oesophagus,  62 
— ■  —  of  rectum,  613,  615 
of  stomach,  203 


INDEX   OF   SUBJECTS 


721 


Scirrhous  carcinoma  of  pylorus,  209 
Scrotum,    rectum    opening  into,  657, 

658,  605 
Senn's  hydrogen  gas  test,  322 

—  operation  of  gastro-enterostomy, 
252 

—  plates,  preparation  of,  253 

bowel  union  by,  535 

Septicasmia  as  a  cause  of  acute  duo- 
denal ulceration,  284 

Shock  in  traumatic  rupture  of  small 
intestine,  307 

—  in  wounds,  intestinal,  315 

—  —  gunshot,  319 

Sigmoid  anus,  formation  of,  550 

in  rectal  ulceration,  589 

Sigmoidectomy,  operation  of,  546 
Sigmoid  flexure,  accumulation,  fffical, 
in,  455 

—  anatomy  of,  427 

—  diverticula  of,  483,  484 

—  length  of,  in  volvulus,  450 

—  misplacement  of,  482 

—  rupture  of,  457 

—  ulcer  of,  433 

Sigmoidostomy,  operation  of,  544,  546 
Sigmoidotomy   in   removal   of   rectal 

foreign  body,  576 

Silver  nitrate  in  rectal  prolapse,  641 

Site,  usual,  of  gastric  ulcer,  178 

Sloughing  of  small  intestine  in  contu- 
sion, 302 

Small-pox,  as  a  cause  of  stenosis  of 
oesophagus,  85 

Smith's  (Greig)  method  of  fixing  sto- 
mach in  gastrostomy,  235 

Solvents,  use  of,  in  impacted  foreign 
body  of  oesophagus,  31 

Spasm  of  oesophagus,  106 

—  of  stomach,  cardiac  orifice  causing 
dilatation  of  oesophagus,  112 

as  a  cause  of  pyloric  obstruc- 
tion, 210 

Spinal  cord,  injury  to,  from  impacted 
fish  bone  in  oesophagus,  23 

Spongy  carcinoma  of  duodenum,  289 

Spur,  formation  of,  in  colectomy,  548 

—  removal  of,  in  colectomy,  555 
Stenosis  {see  under  Stricture) 
Stercoral  ulcer  of  great  intestine,  437, 

456 

Sternum,  blow  on,  as  a  cause  of  dilata- 
tion of  oesophagus,  113 

Stings,  insect,  as  a  cause  of  oeso- 
phagitis, 37 

Stomach  affections  as  a  cause  of 
spasm  of  oesophagus,  107 

—  anatomy,  surgical,  of,  145 

—  aspiration  of,  229 

—  carcinoma  of,  202 


Stomach,  cardiac  orifice,  obstruction 
of,  207 

—  contusioirs  of,  150 

—  dilatation  of,  224 

in  pyloric  obstruction,  213 

—  fistulous   communication    between 
colon  and,  467 

—  foreign  bodies  in,  164 

—  gastric  juice  (see  Gastric  juice) 

—  lavage  of,  228 

—  motor  power  of,  method  of  deter- 
mming,  152 

—  operations  on,  228 

—  physical  examination  of,  153 

—  physiology  of,  147 

—  pylorus  (see  Pylorus) 

—  rupture  of,  157 

—  sarcoma  of,  206 

—  stenosis  of  (see  Stenosis) 

—  structure  of,  146 

—  symptoms   in   carcinoma   of    oeso- 
phagus, 61,  65,  71 

—  tumours  of,  201,  224 

—  ulcer  of,  176 

—  wounds  penetrating,  161 
Strangulation,  internal,  of  small  intes- 
tine (see  Hernia,  internal),  350 

Stricture,  cicatricial,  of  diiodenum,  291 

—  congenital,  of  duodenum,  293 

—  cicatricial,  of  great  intestine,  438 
as  a  cause  of  intussusception, 

447 

due  to  ulcer,  dysenteric,  435 

stercoral,  437 

tubercular,  434 

of  small  intestine,  393 

causes  of,  301,  337,  340,  393, 

413 

symptoms  of,  398 

treatment  of,  400 

—  congenital,  of  small  intestine,  397, 
421 

cicatricial,  of  oesophagus,  84 

as  a  cause  of  dilatation,  112 

of  diverticula,  117 

— differential  diagnosis  of,  69 

dilatation  of,  by  laminaria,  78 

— symptoms  of,  122 

—  congenital,  of  oesophagus,  128 
symptoms  of,  115 

malignant,  of  oesophagus,  58 

—  cicatricial,  of  rectum,  590 

as  a  cause  of  proctitis,  557 

as  a  cause  of  ulceration,  581 

from  pelvic  cellulitis,  674 

from  proctitis,  chronic,  578 

from  ulceration,  584 

—  congenital,  of  rectum,  669 

—  phantom,  of  rectum,  672 

—  ring,  of  rectum,  614,  616,  617 

3  A 


722 


SUEGEEY  OF  THE  ALIMENTAEY  CANAL 


Stricture,  ring,  division  of,  632 

—  of  stomach,  cardiac  oriiice,  207 

pyloric  orifice,  208 

congenital,  210 

due  to  ulcer,  200 

—  of  urethra  as  a  cause  of  rectal  pro- 
lapse, 638 

Structure  of  great  intestine,  427 

—  small  intestine,  297 

—  cesophagus,  3 

—  rectum,  562 

—  stomach,  146 
Subdiaphragmatic   abscess  secondary 

to  gastric  ulcer,  193,  195 
Succussion  in  dilatation  of  stomach, 

214,  225 
Suppuration    of    malignant    tumour, 

great  intestine,  467,  470 
Surgical  anatomy  of  great  intestine, 

425 

of  small  intestine,  297 

of  oesophagus,  1 

of  rectum,  564 

of  stomach,  145 

Suture  of  perforated  gastric  ulcer,  185 

—  union  of  bowel  by,  528 
Abbe's,  531 

Bishop's,  530 

Czerny-Lembert,  529 

Halsted's,  535 

Maunsell's,  532 

Wolfler's,  529 

Syphilis  of  oesophagus,  52 

—  as  a  cause  of  stricture  of  oesophagus, 
81 

of  intestinal  stricture,  394 

—  —  of  rectal  stricture,  591 
Syphilitic  ulceration  of  great  intestine, 

437 

—  —  of  rectum,  584 


Tables,  intestinal : 

Table  of  fifty  cases  carcinoma,  465 

—  of  successful  cases  of  operation 
in  intussusception,  385 

—  —  in   obstruction   due   to  gall- 
stone, 408 

in  internal  strangulation,  362 

—  —  in  volvulus,  392 
. —  oesophageal : 

Weinlechner's  table  of  site  of  stric- 
ture, 86 
—  rectal  : 

Table  of  operations  in  atresia  recti, 
Ander's,  662 

Cripps',  662 

Curling's,  663 

—  —  in     carcinoma     by    perineal 
method,  Cripps',  625 


Tables,  rectal : 

Table  of  operations  in  carcinoma  by 

perineal  method,  Czerny's,  626 
—  —  Lovingsohn's,  626 

—  stomach : 

Table    of    cases    of    gastric    ulcer 
successfully  operated  upon,  188 
Tape-worm,  causing  rupture  of  bowel, 

339 
Taxis,  abdominal,  in  intussusception, 

383 
in  obstruction  due  to  gall-stone, 

405 

in  volvulus,  391 

Teeth,   affections   of,   as   a    cause   of 

spasm  of  oesophagus,  107 
Temperature  in  appendicitis,  499 

—  in  peritonitis,  420 

—  in  rupture,  traumatic,  small  intes- 
tine, 308 

—  in  strangulation,  internal,  360 

—  in  thrombosis,  mesenteric  vessels, 
486 

—  in  wounds,  gunshot,  intestinal,  320 
Tenesmus  in  foreign  bodies  of  rectum, 

573 

—  in  intussusception,  379,  448 

—  in  proctitis,  578 

—  in  prolapse,  rectal,  640 

—  in  stricture,  great  intestine,  440 

—  in  ulceration,  rectal,  586 

Tents,  laminaria,  in  stenosis  of  oeso- 
phagus, 78,  97 

Teratomata  of  rectum,  608 

Tetany  subsequent  to  lavage  of 
stomach,  228 

Thoracic  oesophagotomy,  139 

Thrombotic  appendicitis,  494 

Tonsil  in  appendicitis,  497 

Tonsils,  affections  of,  in  spasm  of  oeso- 
XDhagus,  107 

Tooth  plate,  impaction  of,  in  oeso- 
phagus, 25 

—  removal  of,  by  gastrotomy,  32, 
36 

Torsion  of  oesophagus,  130 

Traction  in  diverticula  of   oesophagus, 

119 
Transfusion  in  excessive  hemorrhage 

from  gastric  ulcer,  180 

—  in  duodenal  ulcer,  282 
Translumination  of  stomach,  155 
Transposition  of  viscera  (bowel),  481, 

422 
Trendelenburg,   position     in    appen- 

dicectomy,  557 
Treves'  operation  in  rectal   prolapse, 

647 
Trocar  and  canula  in  rectal  atresia, 

668 


INDEX   OF  SUBJECTS 


Tubage,  permanent,  of  Gersuny  in  car- 
cinoma of  oesophagus,  77 
Tubercular  appendicitis,  494 

—  ulcer,  intestinal,  839,  434 

—  ulceration,  rectum,  583 
Tuberculosis  of  oesophagus,  52 

—  as  a  cause  of  stenosis,  88 

—  as  a  cause   of  stenosis  of  rectum, 
591 

Tubes,  bone,  in  bowel  union,  537 

—  Paul's  method,  538 

—  india-rubber,  Eobinson's,  539 

—  retained,   in    carcinoma    of    oeso- 
phagus, 74,  77,  79,  81 

Tumours  of  duodenum,  288 

—  of  gi'eat  intestine,  461 

—  of  small  intestine,  410 

—  of  oesophagus,  54 

—  of  rectum,  601 

—  of  stomach,  201 

Tympanites  in  carcinoma  (intestinal), 
470 

—  perforation  (intestinal),  315 

—  thrombosis  of  mesenteric  vessels, 
486 

—  volvulus,  451 

—  wounds,  gunshot,  320 
Typhlitis,  481 

Typhoid  fever  simulating  appendicitis, 
504 

—  ulceration,  341,  433 


Ulcek  of  duodemim,  277 

complications  of,  280 

•  excision  of,  282 

•  fistula  from,  281 

haemorrhage  from,  279 

perforation  of,  280 

prognosis  of,  279 

—  —  symptoms  of,  278 
treatment  of,  282 

—  of  great  intestine,  catarrhal,  437 
dysenteric,  435 

simple,  431 

stercoral,  487, 456 

• syphilitic,  487 

tubercular,  434 

typhoid,  433 

—  of  cesopliagiis,  46 

as  a  cause  of  stenosis,  87 

—  of  sto7nach,  176 

abscess  from,  192 

adhesions  in,  198 

character  of,  177 

contractions,  internal,  in,  199 

diagnosis   from  varix   of    oeso- 
phagus, 50 
excision  of,  179 

—  —  fistulse  secondary  to,  196 


Ulcer  of  stomach,  hfpniorrhage  in,  180 

perforation  of,  181 

situation  of,  ]  76 

stenosis,  pyloric,  from,  200,  210 

symptoms  of,  176 

—  —  treatment  of,  185 
Ulceration  of  diLodenum,  acute,  284 

—  —  relation  of  burns  to,  284 
— of  septicaemia  to,  285 

—  —  symptoms  of,  287 

of  tumour,  malignant,  290 

—  of  great  intestine,  431 

of  appendix,  493 

in  carcinoma,  466 

in  rectal  carcinoma,  617 

in  spinal  cord  lesions,  437 

tubercular,  in  appendicitis,  496 

tyjDhoid  in  appendicitis,  496 

—  of  small  intestine  from  contusion, 
302 

from  foreign  body,  330 

from  gall-stone,  403 

from  tumours,  malignant,  413 

from  tubercular,  339,  393 

from  typhoid,  341,  393 

—  of  cesophagus,  20 

—  of  rectum,  581 

in  diarrhoea,  chronic,  581 

in  diphtheria,  381 

dysentery,  581 

foreign  body,  581,  575,  684 

gonorrhoea,  581 

—  — ■  impaction,  fsecal,  581 

in  inflammation  of  Bartholin's 

gland,  586 

in  injury,  581 

in  parturition,  586 

in  polypus,  581 

in  proctitis,  579 

in  tuberculosis,  583 

in  syphilis,  584 

■  varicose,  581,  595 

symptoms  of,  586 

treatment  of,  586 

as  a  cause  of  periproctitis,  580 

as  a  cause  of  stricture,  590 

—  — -  as  a  sequence  of  stricture,  592, 
670 

Uretero-enterostomy,  operation  of, 
560 

Urethra,  fistulous,  communication  be- 
tween colon  and,  484 

between  rectum  and,  575,  592, 

617 

—  rectum  opening  into  (congenital), 
657,  660,  663,  665 

Urethrotome,  Maisonneuve's,  in  steno- 
sis of  oesophagus,  101 

Urine,  state  of,  in  internal  strangula- 
tion, 360 


724 


SURGERY  OF  THE  ALIMENTARY  CANAL 


Urine,  state  of,  in  traumatic  rupture, 
intestinal,  309 

—  retention  of  in  rectal  prolapse,  640 

—  suppression  of,  after  gastro-entero- 
stomy,  258 

Uterine  intra-inflammation  as  a  cause 
of  intestinal  misplacement,  481 

—  tumours   causing   obstruction,   in- 
testinal, 418 

rectal,  674 

Uterus,    affections    of,   in   spasm   of 
oesophagus,  107 

—  fistulous,  communication  between 
rectum  and,  575,  592,  617,  634 

—  rectum,  opening  into  (congenital), 
658 


Vagina,  fistulous  communication  be- 
tween rectum  and,  575,  592,  617, 
634 

—  rectum  opening  into  (congenital), 
657,  661,  665 

Vaginal  proctectomy,  691 
Vagus,  involvement  of,  in  dilatation  of 
oesophagus,  113 

—  in  paralysis  of  oesophagus,  103 
— -  in  spasm  of  oesophagus,  106 
Valve,  ileo-csecal,  anatomy  of,  429 
Valvulae    conniventes    of    duodenum, 

272 

—  ileum,  298 

—  jejunum,  298 

—  mal-development  of,  in  congenital 
stricture,  397,  422 

Valvular   opening    in   sigmoid    anus, 

formation  of,  553 
Varicose  ulcer  of  rectum,  585,  591 
Varix  of  oesophagus,  49 
Vascular  supply  of  great  intestine,  428 

-of  small  intestine,  299 

of  oesophagus,  3 

of  rectum,  563 

of  stomach,  147 

Vermiform  appendix  {see  Appendix) 
Verneuil's  operation  in  rectal  prolapse, 

649 


Villi  of  duodenum,  272 

—  of  ileum,  298 

—  of  jejunum,  298 

Villous  carcinoma  of  great  intestine, 
466 

—  tumour  of  rectum,  603 
Vitelline  duct,  malformations  of,  420 
Volvulus  of  great  intestine,  449 

—  of  small  intestine,  389 
Vomiting  in  appendicitis,  499 

—  in  carcinoma,  intestinal,  290,  469, 
471 

—  —  rectal,  621 

—  in  gall-stone  obstruction,  403 

—  in  gastric  ulcer,  relation  to  site,  178 

—  in  intussusception,  380,  448 

—  in  peritonitis,  420 

—  in  pyloric  obstruction,  212 

—  in   rupture,   traumatic,   intestinal, 
274,  308 

stomach,  159 

—  in  strangulation,  internal,  359,  364, 
366 

—  in  stricture,  intestinal,  398,  440 

—  in  volvulus,  391,  451 

—  persistent,  after  gastro-enterostomy , 
258 


Warts  of  oesophagus,  54 
Weinlechner's  table  of  site  of  stricture 

of  oesophagus,  86 
Whooping-cough  as  a  cause  of  rectal 

prolapse,  638 
Witzel's  operation  of  gastrostomy,  242 
Wolfler's  gastro-enterostomy,  249 

—  suture  in  bowel  union,  529 
Worms,  intestinal,  as  a  cause  of  proc- 
titis, 577 

—  —  —  prolapse,  rectal,  638 

spasm  of  oesophagus,  107 

Wounds  of  intestine,  313 

—  of  oesophagus,  7 

—  of  rectum,  569 

—  of  stomach,  161,  163 

—  operation,  giving    rise  to  internal 
strangulation,  368 


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menclatureof  the  R.C.P.  Lond.  (Student's 
Guide  Series).  By  Norman  Moore, 
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General  Pathology: 

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Elements  of  Human  Physiology. 

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Principles  of  Human  Physi- 
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prudence at  Guy's  Hospital ;  Official 
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orders. By  TiiEO.  13.  IlYSLOP,  M.D., 
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The  Insane  and  the  Law  :  a 
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Mentally  Afflicted.  With  Hints  to 
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ning  Counsel.  ByG.  Pitt-Lewis,  Q.C, 
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Law.     Svo,   14s. 

Illustrations  of  the  Influence  of 
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By  D.  Hack  Tuke,  M.D.,  F.R.C.P., 
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A    Dictionary   of   Psychological 

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Lunacy  Law  for  Medical  Men. 

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on  Neurology  and  Insanity  to  the  West- 
minster Hospital  Medical  School, and  to  the 
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The  Journal  of  Mental  Science. 

Publislied  Quarterly,  by  Authority  of  the 
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Mental  Affections  of  Childhood 

and  Youth  (Lettsomian  Lectures  for 
1887,  &c.).  By  J.  Langdon-Down, 
M.D.,  F.R.C.P.,  Consulting  Physician  to 
the  London  Hospital.     Svo,  6s. 

Manual  of  Midwifery  : 

Including  all  that  is  likely  to  be  required 
by  Students  and  Practitioners.  By 
Alfred  L.  Galabin,  M.A.,  M.D., 
F.Iv.C.P.,  Obstetric  Physician  to,  and 
Lecturer  on,  Midwifery,  <S:c.,  at  Guy's 
Hospital.  Third  Edition.  Crown  Svo, 
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Sterility. 

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Senior  Physician  to  the  Glasgow  Hospital 
for  Diseases  pecidiar  to  Women.   Svo,  5s. 


and    Ab- 

■V^onaen. 


commencmg 
Joseph    G. 


The  Student's  Guide  to  the 
Practice  of  Midwifery.  By  D. 
Lloyd  Roberts,  M.D.,  F.R.C.P.,  Lec- 
turer on  Clinical  Midwifery  and  Diseases 
of  Women  at  the  Owens  College;  Obstetric 
Physician  to  the  Manchester  Royai  In- 
firmary. Fourth  Edition.  Fcap.  Svo,  with 
Coloured  Plates  and  Engravings. 

[Prefarin^. 

Manual  of  the  Diseases  peculiar 

to  "Women,  By  James  Oliver, 
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Physician  to  the  Plospital  for  Diseases 
of  Women,  London.  Fcap.  Svo,  3s.  6d. 
By  the  same  Aittlior. 

Abdominal     Tumours 

dominal     Dropsy     in 

Crown  Svo,  7s.  6d. 
Obstetric  Aphorisms  : 

For   the    Use   of    Students 
Midwifery     Practice.       By 
Swayne,  M.D.      Tenth  Edition.    Fcap 
Svo,  with  20  Engravings,  3s.  6d. 

Lectures  on  Obstetric  Opera- 
tions ;  Includmg  the  Treatment  of 
Haemorrhage,  and  forming  a  Guide  to 
the  Management  of  Difficult  Labour. 
By  Robert  Barnes,  M.D.,  F.R.C.P., 
Consulting  Obstetric  Physician  to  St. 
George's  Hospital.  Fourth  Edition.  Svo, 
with  121  Engravings,  12s.  6d. 
By  the  same  Atttlior. 

A  Clinical  History  of  Medical 
and  Surgical  Diseases  of 
Women.  Second  Edition.  Svo,  with 
iSl  Engravings,  2Ss. 

Clinical    Lectures   on    Diseases 

of  "Women  :  Delivered  in  St.  Bartho- 
lomew's Hospital,  by  J.  MattheviS 
Duncan,  M.D.,  LL.D.,  F.R.C.P., 
F.R.Ss.  L.  &  E.,  late  Obstetric  Physician 
to  St.  Bartholomew's  Hospital.  Fourth 
Edition.     Svo,  i6s. 

Gynaecological  Operations : 

( Handbook  oO-  By Alban  H.  G.  Doran, 
F.R.C.S.,  Surgeon  to  the  Samaritan  Hos- 
pital.    Svo,  with  167  Engravings,  15s. 

The     Student's    Guide     to     the 

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Obstetric  Physician  to  Guy's  Hospital. 
Fifth  Edition.  Fcap.  Svo,  with  142 
Engravings,  Ss.  6d. 

A  Practical  Treatise  on  the 
Diseases  of  "Women.  By  T.  Gail- 
lard  Thomas,  M.D.  Sixth  Edition, 
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and  at  Dartmouth  Collie.  Roy.  Svo, 
with  347  Engravings,  25s. 

Notes  on  Diseases  of  Women  : 

Specially  designed  to  assist  the  Student  in 
preparing  for  Examination.  By  James 
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Abdominal  Surgery. 

By  J.  Greig  Smith,  M.A.,  F.R.S.E., 
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Professor  of  Surgery,  University  College, 
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The  Physiology  of  Death  from 

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geon to  the  Samaritan  Free  Hospital. 
8vo,   3s.  6d. 

Notes  on  Gynsecological  Nurs- 
ing. By  John  Benjamin  Hellier, 
M.  D. ,  M.  R.  C.  S. ,  Lecturer  on  the  Diseases 
of  Women  and  Children  in  the  Yorkshire 
College,  and  Surgeon  to  the  Hospital  for 
Women,  &c.,  Leeds.     Cr.  8vo,  is.6d. 

A  Manual  for  Hospital    Nurses 

and  others  engaged  in  Attending  on  the 
Sick,  with  a  Glossary.  By  EDWARD  J. 
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Exeter  Hospital.  Eighth  Edition.  Crown 
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A  Manual  of  Nursing,  Medical 

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lingworth,  M.D.,  F.R.C.P.,  Obstetric 
Physician  to  St.  Thomas's  Hospital. 
Third  Edition.  Fcap.  8vo,  with  Engrav- 
ings, 2s.  6d. 

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A    Short    Manual    for    Monthly 

Nurses.  Fourth  Edition.  Fcap.  8vo, 
IS.   6d. 

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For  Practitioners  and  Students.  By  W. 
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ritan Hospital.  Second  Edition.  Crown 
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The  Diseases  of  Children. 

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tion.    Fcap.  8vo,  IDS.  6d. 

A  Practical  Treatise  on  Disease 
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of  the  Belgians,  and  to  the  East  London 
Hospital  for  Children,  &c.  Second 
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Clinical    Studies   of  Disease    in 

Children.  Second  Edition.  Post  8vo, 
7s.  6d. 

Also. 

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and  Children.  Fifth  Edition.  Post 
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mulary. By  Edward  Ellis,  M.D. 
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Materia  Medica  : 

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Materia  Medica, 

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Vegetable   Kingdom  —  Organic    Com- 
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Recent  Materia  Medica. 

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ings, 8s.  6d. 

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8v0,    IDS. 

Royle's      Manual     of      Materia 

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ham.    8vo,  6s. 

Manual  of  Botany. 

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I2S. 

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The  Principles  and  Practice  of 
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The  Practice  of  Medicine  (Stu- 
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versity of  Glasgow.  Seventh  Edition. 
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7 


Treatment  of  Some  of  the  Forms 
of  Valvular  Disease  of  the  Heart. 
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A    Manual    of  Diseases    of  the 

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The  Nervous  System, 

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On  Gallstones,  or  Cholelithiasis. 

By  E.  M.  Brockbank,  M.D.  Vict., 
M.R.C.P.  Lond.,  late  Resident  Medical 
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Health    Resorts   at    Home    and 

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The  Mineral  Waters  of  France 

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Canary  Islands 

Health  Resorts,  in  their  Climatological 
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Honorar}^  Surgeon  to  the  Blackburn  In- 
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Surgery  :  its  Theory  and  Prac- 
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Surgical  Emergencies  : 

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wall Hospital.  Fifth  Edition.  Crown 
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Operations  on  the  Brain  (A 
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A  Course  of  Operative  Surgery. 

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By  the  same  Author. 

The  Student's  Guide  to  Surgical 

Diagnosis.  Second  Edition.  Fcap. 
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Manual  of  Minor   Surgery    and 

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tioners. Tenth  Edition.     Fcap.  8vo,  with 
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Injuries    and    Diseases    of   the 

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Subjects.       Delivered     in     University 
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Surgery. 

By  C.  W.  Mansell  Moullin,  M.A., 
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ings, 34s. 

The  Practice  of  Surgery  : 

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750  Engravings  (many  being  coloured), 
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On  Tension  :  Inflammation  of 
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terian  Lectures,  iSSS.     Svo,  6s. 

The  Surgeon's  Vade-Mecum  : 

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Diseases  of  Bones  and  Joints. 

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Intended  for  Use  on  the  Dead  and  Living 
Subject  alike.  By  W.  H.  A.  Jacobson, 
M.A.,  M.B.,  M.Ch.  Oxon.,  F.R.C.S., 
Assistant  Surgeon  to,  and  Lecturer  on 
Anatomy  at,  Guy's  Hospital.  Third 
Edition.  8vo,  with  many  Illustrations. 
[/«  the  pi-ess. 

On  Anchylosis. 

By  Bernard  E.  Brodhurst,  F.R.C.S., 
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pital. Fourth  Edition.  8vo,  with  En- 
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By  the  same  Author. 

Curvatures  and  Disease   of  the 

Spine.  Fourth  Edition.  8vo,  with 
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Alw. 
Talipes  Equino-Varus,  or  Club- 
foot.    8vo,  with  Engravings,  3s.  6d. 

Surgical  Pathology  and  Morbid 

Anatomy.  By  Anthony  A.  Bowley, 
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Crown  8vo,  with  183  Engravings, 
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Injuries  and  Diseases  of  Nerves 
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8vo,  with  20  Plates,  14s. 

Illustrations  of  Clinical  Surgery. 

By  Jonathan  Hutchinson,  F.R.S., 
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Its  Causes,  Pathology,  and  Treatment. 
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Lateral    and    other     Forms     of 

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Face  and  Foot  Deformities. 

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The  Human  Foot : 

Its  Form  and  Structure,  Functions  and 
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firmary. With  7  Plates  and  Engravings 
(50  Figures).     Svo,  7s.  6d. 

Royal  London  Ophthalmic  Hos- 
pital Reports.  By  the  Medical  and 
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Ophthalmological  Society 

of  the  United  Kingdom.  Transactions, 
Vol.  XV.     Svo,   I2S.   6d. 

The  Diseases  of  the  Eye 

(Student's  Guide  Series).  By  Edward 
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Diseases  and  Refraction  of  the 

Eye.  ByN.  C.  Macnamara,  F.R.C.S., 
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geon to  the  Royal  Westminster  Ophthalmic 
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Diseases  of  the  Eye  :  a  Practical 

Handbook  for  General  Prac- 
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thalmic Surgeon  to  the  Ulster  Hospital 
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On  Diseases  and  Injuries  of  the 

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lege, Glasgow.  With  10  Coloured  Plates 
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Eyelids.  By  C.  Fred.  Pollock, 
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Refraction  of  the  Eye  : 

A  Manual  for  Students.  By  GusTAVUS 
Hartridge,  F.R.C.S.,  Surgeon  to  the 
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Eighth  Edition.  Crown  8vo,  with  loo 
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The  Ophthalmoscope.  A  Manual 
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Methods  of  Operating  for  Cata- 
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Atlas  of  Ophthalmoscopy. 

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H.  RosBOROUGH  Swanzy,  M.B.  Third 
Edition,  4to,  40s. 

Glaucoma : 

Its  Pathology  and  Treatment.  By 
Priestley  Smith,  Ophthalmic  Surgeon 
to,  and  Clinical  Lecturer  on  Ophthalmo- 
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ham, 8vo,  with  64  Engravings  and  12 
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Eyestrain 

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mic Hospital,  Surgeon  and  Ophthalmic 
Surgeon  to  the  Miller  Hospital.  8vo, 
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Diseases  of  the  Eye  : 

A  Handbook  of  Ophthalmic  Practice  for 
Students  and  Practitioners.  By  G.  E. 
de  Schweinitz,  M.D.,  Professor  of 
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Polyclinic.  With  216  Illustrations,  and 
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Diseases  and  Injuries  of  the 
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geon to  St.  George's  Ilospital.  Fourth 
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Diseases  of  the  Ear, 

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Diseases  of  the  Throat  in  the  College, 
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A  System  of  Dental  Surgery. 

By  Sir  John  Tomes,  F.R.S.,  and  C.  S. 
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Crown  8vo,  with  292  Engravings,  15s. 

Dental    Anatomy,    Human    and 

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Warren,  D.D.S.  Roy.  Svo,  with  600 
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Notes  on  Dental  Practice. 

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Papers  on  Dermatology. 

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Venereal  Diseases,  Rush  Medical  College, 
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A  Handbook  on  Leprosy. 

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Medicine  in,  (juy's  Hospital.  Crown 
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Sarcoma  and  Carcinoma  : 

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Hospital.     8vo,  with  4  Plates,  Ss. 

By  the  same  Author. 

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rynx (Sarcoma  and  Carcinoma). 
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On  Cancer  : 

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cal and  Surgical  Treatment.  By  F.  A. 
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Cancer  Hospital,  Brompton.  Svo,  with 
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Cancers  and  the  Cancer  Pro- 
cess :  a  Treatise,  Practical  and  Theoretic. 
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By  the  same  Author. 

Pathology    and     Treatment     of 

Ring-worm.    Svo,  with  21  Engravings, 

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Diseases  of  the  Prostate  : 

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Surgery  of  the  Urinary  Organs. 

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The    Suprapubic    Operation    of 

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The      Cardinal      Symptoms     of 

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A  Practical  Guide  to  the  Analytical 
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ings, 8vo,  7$.  6d. 

Clinical    Chemistry     of    Urine 

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Male     Organs     of     Generation 

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Diseases    of   the     Rectum    and 

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Terminologia       Medica      Poly- 

glotta  :  a  Concise  International  Die 
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15 


Practical  Chemistry 

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Royal  Military  Academy,  and  Artillery 
College, Woolwich.  Svo,  with  Engravings, 
and   Map  of  Spectra,  8s.  6d. 

Analytical  Chemistry. 

Notes  for  Students  in  Medicine.  By 
Albert  J.  Bernays,  Ph.D.,  F.C.S.^ 
F.I.C.     Third  Edition.      Cr.  Svo,  4s.  6d. 

Volumetric  Analysis  : 

(A  Systematic  Handbook  of);  or  theQuan- 
titative  Estimation  of  Chemical  Substances 
by  Measure,  applied  to  Liquids,  Solids,, 
and  Gases.  By  Francis  Sutton,  F.C.S.,. 
F.I.C,  Public  Analyst  for  the  County 
of  Norfolk.  Seventh  Edition.  Svo,  with 
1X2  Engravings,  iSs.  6d. 

Commercial    Organic  Analysis: 

A  Treatise  on   the   Properties,  Modes   of 
Assaying,  Proximate  Analytical  Examina- 
tion, &c.,  of  the  various  Organic  Chemi- 
cals and  Products  employed  in  the   Arts, 
Manufactures,  Medicine,  &c.   By  Alfred^ 
H.  Allen,  F.I.C,  F.C.S.,  Public  Ana- 
lyst for  the  West  Riding  of  Yorkshire,  the 
Northern  Division  of  Derbyshire,  &c. 
Vol.    I. — Alcohols,  Neutral    Alcoholic 
Derivatives,  Sugars,  Starch  and  its 
Isomers,    Vegetable    Acids,     &c. 
With  Illustrations.    Third  Edition. 
8vo.  [Preparing. 

Vol.  II.— Fixed  Oils  and  Fats,  Hydro- 
carbons, Phenols,  &c.  With  Illus- 
trations.    Third  Edition.     Svo. 

[Preparing. 
Vol.    HI. — Part   I.     Aromatic    Acids,. 
Tannins,     Dyes,     and    Colouring 
Matters.     Third  Edition,  Svo. 

[Preparing. 
Vol.  HI.— Part  II.  Amines  and  Am- 
monium Bases,  Hydrazines,  Bases 
from  Tar,  Vegetable  Alkaloids. 
Second  Edition.  Svo,  iSs. 
Vol.  HI.— Part  HI.  Vegetable  Alka- 
loids (concluded),  Non- Basic  Vege- 
table Bitter  Principles,  Animal 
Bases,  Animal  Acids,  Cyanogen 
and  its  Derivatives. 

Cooley's  Cyclopaedia 

of  Practical  Receipts,  and  Collateral  In- 
formation in  the  Arts,  Manufactures,  Pro- 
fessions, and  Trades  :  Including  Medicine, 
Pharmacy,  Hygiene  and  Domestic  Eco- 
nomy. Seventh  Edition,  by  W.  North, 
M.A.  Camb.,  F.C.S.  2  Vols.,  Roy. Svo, 
with  371  Engravings,  42s. 

Chemical  Technology: 

A  Manual.  By  Rudolf  von  Wagner. 
Translated  and  Edited  by  William 
Crookes,  F.R.S.,  from  the  Thirteenth 
Enlarged  German  Edition  as  remodelled 
by  Dr.  Ferdinand  Fischer.  Svo,  with 
596  Engravings,  32s. 


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14 


J.    cV    A.    CHURCHILL'S   RECENT    WORKS. 


Chemical   Technology  ; 

Or,  Chemistry  in  its  Applications  to  Arts 
and  Manufactures.     Edited  by  Charles 
E.     Groves,     F.  R.S.,    and    William 
Thorp,  B.Sc. 
Vol.     I. — Fuel    and    its    Applica- 
tions.     By  E.  J.    Mills,    D.Sc, 
F.R.S.,   and   F.    J.    Rowan,    C.E. 
Royal  8vo,  with  606  Engravings,  30s. 
Vol.    II. — Lighting     by     Candles 
AND    Oil.      By   W.   Y.  Dent,   J. 
McArthur,  L.   Field   and  F.    A. 
Field,   Boverton  Redwood,  and 
D.  A.  Louis.     Royal  8vo,  with  358 
Engravings  and  Map,  20s. 
Vol.    III. — Gas    and    Electricity. 
[Ill  the  press. 

Technological  Handbooks. 

Edited    By    John    Gardner,    F.I.C, 
F.C.S.,  and  James  Cameron,  F.I.C. 
Brewing,    Distilling,   and    Wine 

Manufacture.      Crown  8vo,  with 

Engravings,  6s.  6d. 
Bleaching,    Dyeing,   and    Calico 

Printing.    With  Formulae.    Crown 

8vo,  with  Engravings,  5s. 
Oils,      Resins,     and      Varnishes. 

Crown  8vo,  with  Engravings.    7s.  6d. 
Soaps   and   Candles.     Crown  8vo, 

with  54  Engravings,  7s. 

The  Microscope  and  its  Revela- 
tions. By  the  late  William  B.  Car- 
penter, C.B.,  M.D.,  LL.D.,  F.R.S. 
Seventh  Edition,  by  the  Rev.  W.  II. 
Dallinger,  LL.D.,  F.R.S.  With  21 
Plates  and  800  Wood  Engravings.  Svo, 
26s.      Half  Calf,  30s. 

The  Quarterly  Journal  of  Micro- 
scopical Science.  Edited  by  E.  Ray 
Lankester,  M.A.,  LL.D.,  F.R.S.;  with 
the  co-operation  of  Adam  Sedgwick, 
M.A.,  F.R.S.,  and  W.  F.  R.  Weldon, 
M.A.,    F.R.S.       Each  Number,  ids. 

Methods  and  Formulae 

Used  in  the  Preparation  of  Animal  and 
Vegetable  Tissues  for  Microscopical  Ex- 
amination, including  the  Staining  of 
Bacteria.  By  Peter  Wyatt  Squire, 
F.L.S.     Crown  Svo,  3s.  6d. 

TheMicrotomist'sVade-Mecum: 

A  Handbook  of  the  Methods  of  Micro- 
scopic Anatomy.  By  Arthur  Bolles 
Lee,  Assistant  in  the  Russian  Laboratory 
of  Zoology  at  Villefranche-sur-mer  (Nice). 
Fourth  Edition.     Svo,  15s. 


Photo- Micrography 

(Guide  to  the  Science  of).  By  Edward 
C.  BousFiELD,  L.R.C.P.  Lond.  Svo, 
with  34  Engravings  and  Frontispiece,   6s. 

An     Introduction    to     Physical 

Measurements,  with  Appendices  on 
Absolute  Electrical  Measurements,  &c. 
By  Dr.  F.  Kohlrausch,  Professor  at 
the  University  of  Strassburg.  Third 
Edition,  translated  from  the  Seventh 
German  Edition,  by  Thomas  Hut- 
chinson Waller,  B.A.,  B.Sc,  and 
Henry  Richardson  Procter,  F.I.C, 
F.C.S.  Svo,  withgi  Illustrations,  12s.  6d. 

Tuson's  Veterinary  Pharma- 
copoeia, including  the  Outlines  of 
Materia  Medica  and  Therapeutics. 
Fifth  Edition.  Edited  by  James  Bayne, 
F.  C.S.,  Professor  of  Chemistry  and 
Toxicology  in  the  Royal  Veterinary 
College.     Crown  Svo,  7s.  6d. 

The  Principles  and  Practice  of 

Veterinary  Medicine.  By  William 
Williams,  F.R.C.V.S.,  F.R.S.E., 
Principal,  and  Professor  of  Veterinary 
Medicine  and  Surgery  at  the  New  Veter- 
inary College,  Edinburgh.  Seventh  Edi- 
tion. Svo,  with  several  Coloured  Plates 
and  Woodcuts,  30s. 

By  ike  same  Author. 

The     Principles     and     Practice 

of  Veterinary  Surgery.  Eighth 
Edition.  Svo,  with  9  Plates  and  147 
Woodcuts,   30s. 

The  Veterinarian's  Pocket  Re- 
membrancer :  being  Concise  Direc- 
tions for  the  Treatment  of  Urgent  or 
Rare  Cases,  embracing  Semeiology, 
Diagnosis,  Prognosis,  Surgery,  Thera- 
peutics, Toxicology,  Detection  of  Poisons 
by  their  Appropriate  Tests,  Hygiene,  &c. 
By  George  Armatage,  M.R.C.V.S. 
Second  Edition.     Post  Svo,  3s. 

Chauveau's  Comparative  Anat- 
omy of  the  Domesticated  Ani- 
mals. Revised  and  Enlarged,  with  the 
Co-operation  of  S.  Arloing,  Director  of 
the  Lyons  Veterinary  School,  and  Edited 
by  George  Fleming,  C.B.,  LL.D., 
F.R.C.V.S.,  late  Principal  Veterinary 
Surgeon  of  the  British  Army.  Second 
English  Edition.     Svo,  with  585  Engrav- 


ings, 3 


IS.  6d. 


LONDON:    7,    GREAT  MARLBOROUGH  STREET. 


INDEX    TO    J.    &    A.    CHURCHILL'S    LIST. 


/Adams  (W.)  on  Clubfoot,  g 
on  Contractions  of  the  Fingers,  &c.,  9 

on  Curvature  of  the  Spine,  9 

•  tVllen's  Chemistry  of  Urine,  12 

Commercial  Organic  Analysis,  13 

.Vrmatage's  Veterinary  Pocket  Remembrancer,  14 

Barnes  (R.)  on  Obstetric  Operations,  3 

on  Diseases  of  Women,  3 

'Heale  (L.  S.)  on  Liver,  6 

Microscope  in  Medicine,  6 

Slight  Ailments,  6 

Urinary  and  Renal  Derangements,  12 

'"Beale(P.  T.  B.)  on  Elementary  Biology,  2 
ilieasley's  Book  of  Prescriptions,  5 

Druggists'  General  Receipt  Book,  5 

Pocket  Formulary,  5 

J}!ell  on  Sterility,  3 

Bellamy's  Sui\gical  Anatomy,  i 

I'.entley  and  Trimen's  Medicinal  Plants,  5 

Bentley's  Systematic  Botany,  5 

Berkart's  Bronchial  Asthma,  6 

Bernard  on  Stammering,  7 

C'ernay's  Notes  on  Analytical  Chemistry,  i 
Bigg's  Short  Manual  of  Orthopfedy,  g 
Bloxam's  Chemistry,  12 

Laboratory  Teaching,  12 

Bousfield's  Photo-Micrography,  14 
Bovvlby's  Injuries  and  Diseases  of  Nerves,  9 

Surgical  Pathology  and  Morbid  Anatomy,  9 

Brockbank  on  Gallstones,  8 

Brodhurst's  Anchylosis,    g 

Curvatures,  &c.,  of  the  Spine,  9 


Talipes  Equino-Varus,  9 


Bryant's  Practice  of  Surgery,  8 

Tension,  Inflammation ofBone,Injuries,&c.,  8 

Burckhardt's    (E.)  and  Fenwick's  (E.   H.)  Atlas    of 

Cystoscopy,  11 
Burdett's  Hospitals  and  Asylums  of  the  World,  2 
Butlin's  Malignant  Disease  of  the  Larynx,  11 

Operative  Surgery  of  Malignant  Disease,  ii 

Sarcoma  and  Carcinoma,  11 

Buzzard's  Diseases  of  the  Nervous  System,  7 
Peripheral  Neuritis,  7 

Simulation  of  Hysteria,  7 

'Cameron's  Oils,  Resins,  and  Varnishes,  14 

SoBps  and  Candles,  14 

•Carpenter  and  Dallinger  on  the  Microscope,  14 
■Carpenter's  Human  Physiology,  2 
'Charteris  on  Health  Resorts,  8 

— Practice  of  Medicine,  6 

Chauveau's  Comparative  Anatomy,  14 

■Chevers'  Diseases  of  India,   5 

Churchill's  Face  and  Foot  Deformities,  9 

Clarke's  Eyestrain,  10 

Clouston's  Lectures  on  Mental  Diseases,  2 

Clowes  and  Coleman's  Quantitative  Analysis,  13 

_ Elementary  Analysis,  13 

Clowes'  Practical  Chemistry,  13 

('ooley's  CyclopjEclia  of  Practical  Receipts,  13 

Cooper  on  Syphilis,  12 

Cooper  and  Edwards'  Diseases  of  the  Rectum,  12 

Cripps'  (H.)  Cancer  of  the  Rectum,  12 

Diseases  of  the  Rectum  and  Aims,  12 

Air  and  Fa;ces  in  Urethra,  12 

Cripps'  (R.  A.)  Galenic  Pharmacy,  4 
Cullingworth's  Manual  of  Nursing,  4 

1 ■_ Short  Manual  for  Monthly  Nurses,  4 

Dalby's  Diseases  and  Injuries  of  the  Ear,  10 

Short  Contrib\itions,  10 

Day  on  Diseases  of  Children,  4 

on  Headaches.  8 

Domville's  Manual  for  Niirses,  4 

Doran's  Gynaecological  Operations,  3 

Druitt's  Surgeon's  Vade-Mecum,  8 

Duncan  (A.j,  on  Prevention  of  Disease  in  Tropics,  5 

Duncan  (J.  M.),  on  Diseases  of  Women,  3 

Dunglison's  Dictionai-y  of  Medical  Science,  12 

Ellis's  (E.)  Diseases  of  Children,  4 

EI!is's(T.  S.)  Human  Foot,  g 

Fagge's  Principles  and  Practice  of  Medicine,  6 

Fayrer's  Climate  and  Fevers  of  India,  5 

Natural  History,  &c.,  of  Cholera,  5 

Fenwick  (E.  H.),  Electric  Illumination  of  Bladder,  11 

—    Symptoms  of  Urinary  Diseases,  11 

Fenwick's  (S.)  Medical  Diagnosis,  6 
Obscure  Diseases  of  the  Abdomen,  6 


Fenwick's  (S.)  Outlines  of  Medical  Treatment,  6 

The  Saliva  as  a  Test,  6 

Fink's  Operating  for  Cataract,  10 

Flower's  Diagrams  of  the  Nerves,  i 

Fowler's  Dictionary  of  Practical  Medicine,  6 

Fox's  (T.)  Atlas  of  Skin  Diseases,  10 

Fox  (Wilsori),AtlasofPathological  AnatomyofLungs,  6 

Treatise  on  Diseases  of  the  Lungs,  6 

Frankland  and  Japp's  Inorganic  Chemistry,  13 
Fraser's  Operations  on  the  Brain,  8 
Fresenius'  Qualitative  Analysis,  13 

Quantitative  Analysis,  13 

Galabin's  Diseases  of  Women,  3 

Manual  of  Midwifery,  3 

Gardner's  Bleaching,  Dyeing,  and  Calico  Printing,  14 

Brewing,  Distilling,  and   Wine   Manuf.  14 

Gimlette  on  Myxcedema,  6 

Codlee's  Atlas  of  Human  Anatomy,  i 

Goodhart's  Diseases  of  Children,  4 

Gowers    Diagnosis  of  Diseases  of  the  Brain,  7 

Manual  of  Diseases  of  Nervous  System,  7 

Clinical  Lectures,  7 

Medical  Ophthalmoscopy,  7 

— ■ —  Syphilis  and  the  Nervous  System,  7 

Granville  on  Gout,  7 

Green's  Manual  of  Botany,  5 

Groves'  and  Thorp's  Chemical  Technology,  14 

Guy's  Hospital  Reports,  7 

Habershon's  Diseases  of  the  Abdomen,  7 

Haig's  Uric  Acid,  6 

Harley  on  Diseases  of  the  Liver,  7 

Harris's  (V.  D.)  Diseases  of  Chest,  6 

Harrison's  Urinary  Organs,  11 

Hartridge's  Refraction  of  the  Eye,  10 

Ophthalmoscope,  10 

Hawthorne's  Galenical  Preparations  of  B  P  ,  4 
Heath's  Certain  Diseases  of  the  Jaws,  8 

Clinical  Lectures  on  Surgical  Subjects,  8 

Injuries  and  Diseases  of  the  Jaws,  S 

Minor  Surgery  and  Bandaging,  8 

Operative  Surgery,  8 

•     Practical  Anatomy,  i 

Surgical  Diagnosis,  8 

Hellier's  Notes  on  Gynajcological  Nursing,  4 
Higgens'  Ophthalmic  Out-patient  Practice,  10 
Hill  on  Cerebral  Circulation,  2 
Hillis'  Leprosy  in  British  Guiana,  10 
Hirschfeld's  Atlas  of  Central  Nervous  System,  2 
Holden's  Human  Osteology, 

Landmarks,  i 

Hooper's  Physicians'  Vade-Mecum,  5 
Hovell's  Diseases  of  the  Ear,  10 
Howden's  Index  Pathologicus,  2 
Hutchinson's  Clinical  Surgery,  9 
Hyde's  Diseases  of  the  Skin,  10 
Hyslop's  Mental  Physiology,  3 
Impey  on  Leprosy,  10 
Jacobson's  Male  Organs  of  Generation,  12 

Operations  of  Surgery,  9 

Johnson's  Asphyxia,  6 

Medical  Lectures  and  Essays,  6 

Cholera  Controversy,  6 

—   Granular  Kidney,  6 


Journal  of  Mental  Science, 

Keyes'  Genito-Urinary  Organs  and  Syphilis,  12 

Kohlrausch's  Physical  Measurements,  14 

Lancereaux's  Atlas  of  Pathological  Anatomy,  2 

Lane's  Rheumatic  Diseases,  7 

Langdon-Down's  Mental  Affections  of  Childhood,  3 

Lee's  Microtomists'  Vade  Mecum,  14 

Lescher's  Recent  Materia  Medica,  4 

Lewis  (Bevan)  on  the  Human  Brain,  2 

Liebreich's  Atlas  of  Ophthalmoscopy,  10 

MacMunn's  Clinical  Chemistry  of  Urine,  12 

IMacnamara's  Diseases  and  Refraction  of  the  Eye, 

; ; of  Bones  and  Joints,  8 

McNeill's  Epidemics  and  Isolation  Hospitals,  2 

Malcolm's  Physiology  of  Death,  4 

Mapother's  Papers  on  Dermatology,  10 

Martin's  Ambulance  Lectures,  8 

iNIaxwell's  Terminologia  iMedica  Polyglotta,  12 

Mayne's  Medical  Vocabulary,  12 

Mercier's  Lunacy  Law,  3 

^iicroscopical  Journal,  14 

Mills  and  Rowan's  Fuel  and  its  Applications,  14 

iMoore's  (N  )  Pathological  Anatomy  of  Diseases,  i 

\Con!iii7icd  on  the  next  /•/le- 


LONDON:    7,    GREAT   MARLBOROUGH  STREET. 


Index  to  J.  &  A.  Churchill's  List — conlinued. 


Moore's  fSir  W.  J.)  Family  Medicine  for  India,  s 

Manual  of  the  Diseases  of  India^  5 

Tropical  Climates,  5 

Morris's  Human  Anatomy,  i 
Moullin's(Mansell)  Surgery,  8 
Nettleship's  Diseases  of  the  Eye,  9 
Notter  and  Firth's  Hygiene,  2 
Oliver's  Abdominal  Tumours,  3 

Diseases  of  Women,  3 

Ophthalmic  (Royal  London)  Hospital  Reports,  9 

Ophthalmological  Society's  Transactions,  9 

Ormerod's  Diseases  of  the  Nervous  System,  7 

Owen's  Materia  Medica,  4 

Parkes'  (E.A.)  Practical  Hygiene,  2 

Parkes'  (L.C.)  Elements  of  Health,  2 

Psvy's  Carbohydrates,  5 

Pereira's  Selecta  e  Prescriptis,  4 

Phillips'  Materia  Medica  and  Therapeutics,  4 

Pitt-Lewis's  Insane  and  the  Law,  3 

Pollock's  Histology  of  the  Eye  and  Eyelids,  9 

Proctor's  Practical  Pharmacy,  4 

Purcell  on  Cancer,  11 

Pye-Smith's  Diseases  of  the  Skin,  11 

Quinby's  Notes  on  Dental  Practice,  10 

Ramsay's  Elementary  Systematic  Chemistry,  13 

Inorganic  Chemistry,  13 

Reynolds'  Diseases  of  Women,  3 
Richardson'.s  INIechanical  Dentistry,  10 
Roberts'  (D.  Lloyd)  Practice  of  Midwifery,  3 
KobirisoH's  (Tom)  Eczema.,  II 

Illustrations  of  Skin  Diseases,  11 

Syphilis,  11 

Ross's  Aphasia,  7 

Diseases  of  the  Nervous  System,  7 

Royle  and  Harley's  Materia  Medica,  5 
St.  Thomas's  Hospital  Reports,  7 
Sansom's  Valvular  Disease  of  the  Heart,  7 
Schetelig's  Homburg  Spa,  8 
Schweinttz's  (G.  E.  de)  Diseases  of  Eye,  10 
Shaw's  Diseases  of  the  Eye,  g 
Short  Dictionary  of  Medical  Terms,  12 
Silk's  Manual  of  Nitrous  Oxide,  10 
Smith's  (E.)  Clinical  Studies,  4 

Diseases  in  Children,  4 

Wasting  Diseases  of  Infants  and  Children, 4 

Smith's  (J.  Greig)  Abdominal  Surgery,  4 

Smith's  (Priestley)  Glaucoma,  10 

Snow's  Cancer  and  the  Cancer  Process,  11 

Palliative  Treatment  of  Cancer,  11 

Reappearance  of  Cancer,  11 

Southall's  Materia  Medica,  5 

Squire's  (P.)  Companion  to  the  Pharmacopoeia,  4 


Squire's  (P  )  London  Hospitals  Pharmacopoeias,  4 

Methods  and  Formulae,  14 

Starling's  Elements  of  Human  Physiology,  2 
Sternberg's  Bacteriology,  6 
Stevenson  and  Murphy's  Hj^giene,  2 
Sutton's  (H.  G),  Lectures  on  Pathology,  i 
Sutton's  (J.  B.)!  General  Pathology,  i 
Sutton's  (F.)  Volumetric  Analysis,  13 
Swain's  Surgical  Emergencies,  8 
S Wayne's  Obstetric  Aphorisms,  3 
Taylor's  (A.  S.)  Medical  Jurisprudence,  2 
Taylor's  (F.)  Practice  of  Medicine,  6 
Tajdor's  (j.  C),  Canary  Islands,  8 
Thin's  Cancerous  Affections  of  the  Skin,  11 

Pathology  and  Treatment  of  Ringworm,  11 

Thomas's  Diseases  of  Women,  3 
Thompson's  (Sir  H.)  Calculous  Disease,  11 

Diseases  of  the  Prostate,  it 

Diseases  of  theUrinaryOrgans,ir 

Lithotomy  and  Lithotrity,  11 

Stricture  of  the  Urethra,  11 

Suprapubic  Operation,  1  r 

Surgery  of  theUrinary  Organs, II 

-_ Tumours  of  the  Bladder,  11 

Thome's  Diseases  of  the  Heart,  7 

Tirard's  Prescriber's  Pharmacopceia,  5 

Tomes'  (C.  S.)  Dental  Anatomy,  lo 

Tomes'  (J.  and  C.  S.)  Dental  Surgery,  10 

Tooth's  Spinal  Cord,  7 

Treves  and  Lang's  German-English  Dictionary,  12 

Tuke's  Dictionary  of  Psychological  Medicine,  3 

Influence  of  the  Mind  upon  the  Body,  3 

Tuson's  Veterinary  Pharmacopoeia,  14 

Valentin  and  Hodgkinson's  Qualitative  Analysis,  13^ 

Vintras  on  the  Mineral  Waters,  &c.,  of  France,  8       \ 

Wagner's  Chemical  Technology,  13 

Walsham's  Surgery :   its  Theory  and  Practice,  8 

Waring's  Indian  Bazaar  Medicines,  5 

Practical  Therapeutics,  5 

Watts'  Manual  of  Chemistry,  12 

West's  (S.)  How  to  Examine  the  Chest,  6 

Westminster  Hospital  Report,  7 

White's  (Hale)  Materia  Medica,  Pharmacy,  &c.,  4 

Wilks'  Diseases  of  the  Nervous  System,  7 

Williams'  Veterinary  Medicine,  14 

— ; ; Surgery,  14 

Wilson's  (Sir  E.)  Anatomists'  Vade-Mecum,  i 
Wilson's  (G.)  Handbook  of  Hygiene,  2 
Wolfe's  Diseases  and  Injuries  of  the  Eye,  g 
Wynter  and  V/ethered's  Practical  Pathology,  i 
Year-Book  of  Pharmacy,  5 
Yeo's  (G.  F.)  Manual  of  Physiology,  2 


N.B. — J.  <^  A.  Churchiirs  larger  Catalogue  of  about  600  works  on  Anatomy^ 
Physiology^  Hygiene,  Midwifery,  Materia  Medica,  Medicine,  Surgery,  Chemistry, 
Botany,  <^'c.  ^c,  with  a  complete  Index  to  their  Std^jects,  for  easy  referettce, 
will  be  forwarded  post  free  on  application. 


America. — J.  ^  A.  CJuirchill  being  in  constant  comvinnication  tvith 
various  publishing  /unises  in  America  are  able  to  conduct  negotiations 
favourable  to  English  Authors. 


lONDON:    7,    GREAT  MARLBOROUGH   STREET. 


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sumerv  of  the  aliment 


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